. 



LIBRARY OF CONGRESS. 



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UNITED STATES OF AMERICA. I 






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WORKS BY 
CONDICT W. CUTLER, M.S., M.D. 



Manual of Differential Medical Diagnosis. — (In 

Students' Manuals Series) i6mo, cloth . . . $1.25 

Differential Diagnosis of the Diseases of the 
Skin. — (In Students' Manuals Series) i6mo, 
cloth 1.25 

Essentials of Physics and Chemistry, Written 
Especially for the Use of Students in Medicine. 
Third edition, revised and enlarged, 8vo . . 2.00 

Practical Lectures in Dermatology. — Compri- 
sing a Course of Fifteen Lectures Delivered at 
the University of Vermont, Medical Department, 
during the Session of 1892 and 1893. 8vo . 2.00 



G. P. PUTNAM'S SONS, New York & London 



PRACTICAL LECTURES IN 
DERMATOLOGY 



COMPRISING A COURSE OF FIFTEEN LECTURES DELIVERED AT 

THE UNIVERSITY OF VERMONT MEDICAL DEPARTMENT 

DURING THE SESSION OF 1892 AND 1893 



/' 



CONDICT W. CUTLER, M.S., M.D. 

PROFESSOR OF DERMATOLOGY, UNIVERSITY OF VERMONT ; PHYSICIAN-IN-CHIEF AND 

DERMATOLOGIST TO THE NEW YORK DISPENSARY ; FELLOW OF THE NEW YORK 

ACADEMY OF MEDICINE ; MEMBER OF THE AMERICAN DERMATOLOGICAL 

ASSOCIATION; AUTHOR OF "DIFFERENTIAL MEDICAL DIAGNOSIS," 

" DIFFERENTIAL DIAGNOSIS OF THE DISEASES OF THE SKIN," ETC. 



'MAY 6 1894'. 



J) 



T^z. ^ 



G. P. PUTNAM'S SONS 



NEW YORK LONDON 

27 -WEST TWENTY-THIRD STREET 24 BEDFORD STREET, STRAND 

®be ^nicktrbockcr ||ttgg 
1894 






Copyright, 1894 

BV 

CONDICT W. CUTLER 



Electrotyped, Printed, and Bound by 

Ube Iftnicfecrbocfcer press, IRew ]t>or& 
G. P. Putnam's Sons 



DR. J. H. WOODWARD, M.S., M.D. 

PROFESSOR OF DISEASES OF THE EYE IN THE UNIVERSITY OF VERMONT 

MEDICAL DEPARTMENT, AND SECRETARY OF THE FACULTY 

THIS WORK IS DEDICATED 

IN ADMIRATION OF HIS ABILITY AS A 

SURGEON AND CLINICAL TEACHER 



PREFACE. 

Having been requested by the students in the Medical 
Department of the University of Vermont to publish my 
lectures on Disease of the Skin, delivered to them during 
the sessions of 1892 and '93, I offer this as my excuse 
for the creation of another work on Dermatology. 

The following pages are prepared from stenographic 
notes and represent with substantial accuracy the lectures 
as they were delivered to the students. As the subject 
was large and the number of lectures small, I endeavored 
to make the course as practical as possible and considered 
only those diseases of the skin which every physician in 
general practice should at least be able to diagnose and 
to treat in an intelligent manner. 

If I have succeeded in making such a presentation of 
the subject these lectures should be found of service not 
only to the student but to the physician engaged in 
general practice. 

260 WEST 57TH ST., 
NEW YORK. 



CONTENTS. 



PAGE 

LECTURE I. 

Anatomy of the Skin ; Lesions of the Skin ; Classification 

and Diagnosis 1-14 

LECTURE II. 
General Therapeutics 15-30 

LECTURE III. 
Acne ; Alopecia, and Alopecia Areata .... 31-48 

LECTURE IV. 

Asteatosis ; Chloasma ; Clavus ; Comedo ; Dermatitis 

Venenata ; and Ecthyma 49-64 

LECTURE V. 
Eczema 65-79 

LECTURE VI. 

Epithelioma ; Erysipelas ; Erythema, Erythema Multi- 
forme, and Erythema Nodosum 80-98 

LECTURE VII. 

Feigned Skin Diseases ; Furunculosis ; Herpes ; Herpes 

Zoster ; and Hyperidrosis 99-115 

vii 



viii CONTENTS. 

PAGB 

LECTURE VIII. 

Hypertrichosis ; Impetigo, Impetigo Contagiosa ; Keloid ; 
Keratosis Pilaris ; Lentigo ; Leucoderma ; Lichen 
Planus; and Lichen Tropicus 116-131 

LECTURE IX. 

Lupus Erythematosus ; Lupus Vulgaris ; Milium ; and 

molluscum contagiosum 132-i43 

LECTURE X. 

Njevus ; Pediculosis ; Pemphigus ; Pityriasis Rosea ; and 

Pruritus 144-156 

LECTURE XL 
Psoriasis and Purpura 157-168 

LECTURE XII. 
Rosacea ; Scabies ; Seborrhea ; Sudamina ; and Sycosis 169-184 

LECTURE XIII. 
Syphilodermata 185-199 

LECTURE XIV. 
Tinea 200-215 

LECTURE XV. 

Tuberculosis of the Skin ; Urticaria ; Verruca ; and 100 

Dermatological Don'ts 216-230 

INDEX 231-238 



PRACTICAL LECTURES IN 

DERMATOLOGY. 



LECTURE I. 

ANATOMY OF THE SKIN, LESIONS OF THE SKIN, CLASSI- 
FICA TION A ND DIA GNOSIS OF SKIN DISEA SES. 

Gentlemen ; 

Many of you have doubtless heard that skin dis- 
eases were formerly divided into three grand divisions. 
In the first division were those which could be cured by 
mercury ; in the second were those which could be cured 
by sulphur ; and in the third were those which the Devil 
himself could not cure. If you start out with any such 
idea it will not be long before you discover that the largest 
number of skin diseases belong to this third class, and 
that the Devil must have neglected his studies in der- 
matology. 

You may be successful practitioners without much 
knowledge of diseases of the skin, but I can tell you that 
it will be very comforting one of these days when called 
upon to treat some skin affection, to be able to call it 
something besides eczema, and to prescribe some other 
remedy than zinc ointment. 



2 LECTURES IN DERMATOLOGY. 

The skin is a very much neglected organ, and at the 
same time one frequently the seat of disease. It is the 
largest organ in the body, and upon the proper perform- 
ance of its functions the health and comfort of the indi- 
vidual depend. It is, therefore, but right that we who 
study the healing art should not be entirely neglectful of 
so large and important a part of the human body. 

With this object in view I will endeavor to quickly 
bring to your notice a few points pertaining to the study, 
diagnosis, and treatment of some of the most common 
skin affections. I will not burden your memories with the 
names of the large number of skin diseases, many of which 
are so rare and unimportant that you will seldom be 
called upon to treat them, but I will ask you to give close 
attention to these few lectures, which we will call your 
introduction to dermatology. 

ANATOMY OF THE SKIN. 

It will be necessary in the first place for you to under- 
stand a little something about the anatomy of the skin. 

The skin is composed of two principal layers. The 
lower or deeper one is called the corium, cutis vera, derma, 
or true skin ; the outer one is named the epidermis, cuticle, 
or scarf skin. 

The derma or corium is that portion of the skin which 
constitutes the leather of commerce. It is composed of 
connective-tissue fibres, which interlace and form a texture 
resembling felt. 

At the deepest part of this corium the fibres are spread, 
and between them are found masses of fat globules consti- 
tuting adipose tissue. In the outer portion the fibres are 
closely matted together, the surface externally rising into 



ANA TOM Y OF THE SKIN. 3 

minute prominences called papillae, and sometimes de- 
scribed as the papillary layer of the skin. 

The epidermis or scarf skin is composed of roundish 
elements called cells. The deeper cells are rounded or 
many-sided, succulent, and composed of what is known as 
the rete mucosum or rete Malpighii. This rests directly 
upon the papillae, and dips down in the inter-spaces 
between them. In the cells of this deeper layer is found 
the pigment or coloring matter of the skin. In patho- 
logical conditions this coloring matter may be very much 
increased or diminished in amount. In negroes it is 
normally present in large amount. In the outer layer of 
the epidermis, called also the horny layer of the skin, the 
cells are flatter, hardened, and lifeless, and are thrown off 
or removed by friction. 

In the corium or true skin are found blood-vessels, 
nerves, lymphatics, muscular fibre, hair follicles, sebaceous 
glands, and sweat glands. 

The hair follicles may be considered as prolongations 
downward into the corium of the epidermal layers sur- 
rounding the penetrating hairs. At the bottom of the 
hair follicle thus formed the fibrous elements of the corium 
rise and form what is known as the hair papilla or bulb, 
from which the hair is supposed to take its growth. The 
hair itself is composed like the epidermis of cells. With- 
in the follicles these cells are succulent, round or polygo- 
nal in shape. Outside they are flattened and elongated, 
appearing like fibres, and these constitute the entire 
length of the hair. 

The sebaceous glands are almost always connected with 
hairs, of some size, and discharge their secretion's into the 
hair follicles. Generally there are two sebaceous glands 
to each hair, situated on opposite sides. They are very 



4 LECTURES IN DERMATOLOGY. 

minute affairs, situated in the outer portion of the corium, 
and their main function appears to be to keep the skin 
and hairs in a flexible state. 

The muscles of the skin, which are connected with the 
hair follicles and sebaceous glands, are attached to the 
lower portion of the hair follicle, and running diagonally 
are inserted in the upper portion of the corium, so that 
each time they contract, pressure is made upon the glands, 
and their contents are forced out. When these muscles 
contract under the influence of cold or mental excitement 
the surface presents minute elevations called cutis anserina, 
or goose skin. 

The sweat, coil, or sudoriparous glands are in the form 
of minute tubes coiled up in the deepest portion of the 
corium, or even in the subcutaneous tissue. Their ducts 
extend through the entire thickness of the skin, and after 
making several spiral turns open directly upon the outer 
surface. The action of these little glands is continuous, 
and sweat is incessantly exudated in the form of sensible 
or insensible perspiration. 

The nails are altered portions of the epidermis. Each 
nail grows from a root, just as each hair starts from its 
root. It only slides over its matrix or bed, so that injury 
to the matrix need not cause a disfigured nail other than 
of the portion directly injured ; whereas injury or disease 
of its root, or where it starts, will generally cause the 
destruction or a deformity of the whole nail. 

SKIN LESIONS. 

The lesions occurring in skin diseases may be either 
primary or secondary. 

The primary lesions are eight in number, and are mac- 



SKIN LESIONS. 5 

ules, papules, vesicles, blebs, pustules, wheals, tubercles, 
and tumors. 

The secondary lesions are six in number, and are crusts, 
scales, excoriations, fissures, ulcers, and scars. 

Macules are colored portions of altered skin, neither 
elevated nor depressed. 

Papules are circumscribed, solid elevations of the skin, 
and are described according to their shape as acuminated, 
rounded, flat, or umbilicated. 

Vesicles are circumscribed, non-purulent, fluid elevations 
of the epidermis, and named like the papules according to 
theii shape. 

Blebs are irregular-shaped, fluid elevations of the epi- 
dermis larger than vesicles. 

Pustules are circumscribed, fluid elevations of the epi- 
dermis containing pus, and like the papule and vesicle 
may be acuminated, rounded, flat, or umbilicated. 

Wheals are flat, raised, solid elevations of the skin of an 
evanescent character. 

Tubercles are circumscribed, solid elevations of the 
skin, firmer, deeper, and usually larger than the papule. 

Tumors are of various sizes. Usually they are large 
prominences of the skin extending into the subcutaneous 
tissues. 

Crusts are dried products of the diseases of the skin. 

Scales are laminated epidermis separated from the skin. 

Excoriations are superficial losses of tissue from the 
skin. 

Fissures are cracks in the epidermis or skin. 

Ulcers are excavations in the skin, the result of molecu- 
lar death. 

Scars are formations of cicatricial tissue in the skin 
taking the place of the normal integument. 



6 LECTURES IN DERMATOLOGY. 

CLASSIFICATION OF SKIN DISEASES. 

If we could classify diseases of the skin according to 
the lesions presented, it would very much simplify their 
study ; but this is impossible, for very few of the diseases 
are distinctly macular or papular in character — that, is the 
lesions are not of one kind, but multiple. Then again, 
many of the skin lesions in a particular disease change in 
character from day to day. That is, the eruption may be 
macular to-day, papular to-morrow, and pustular the next 
day, so you can readily see how difficult it would be to 
classify skin diseases in any such simple way. The best 
dermatologists, both in this country and abroad, no 
longer classify skin diseases or divide them into groups, 
as was formerly done, but simply treat them as en- 
tirely distinct diseases. The American Dermatological 
Association have named and classified alphabetically the 
diseases of the skin as follows : 

Diseases of the Skin. 

Acne Atrophia pilorum propria 

Actinomycosis Atrophia senilis 

Albinismus Atrophia striata 

Alopecia (Baldness) Atrophia unguis 

Alopecia areata Bromidrosis 
Alopecia furfuracea (Dandruff) Callositas 

Ancesthesia Canities 

Angioma Carcinoma 

Angioma cavernosum Chloasma (Liver spots) 

Anidrosis Chromidrosis 
Anthrax simplex (Carbuncle) Cicatrix 

Anthrax maligna Clavus (Corn) 

Asteatosis (Xeroderma) Comedo (Black-heads) 

Atrophia maculosa Cornu cutaneum 



CLASSIFICATION OF SKIN DISEASES. 



Dermatalgia 
Dermatitis calorica 
Dermatitis exfoliativa 
Dermatitis gangraenosa 
Dermatitis herpetiformis 
Dermatitis medicamentosa 
Dermatitis papillaris capillitii 
Dermatitis traumatica 
Dermatitis venenata (Ivy 

poison) 
Ecthyma 
Eczema : 

a. erythematosum 

b. papillosum 

c. vesiculosum 

d. madidans 

e. pustulosum 

f. rubrum 

g. squamosum 
Elephantiasis 
Epithelioma 
Equinia 
Erysipelas 

Erythema multiforme 
Erythema nodosum 
Erythema simplex 
Erythrasma 
Feigned Skin Diseases 
Fibroma 
Frambcesia 
Furunculus (Boils) 
Granuloma fungoides 
Herpes simplex 
Herpes zoster 
Hyperesthesia 



Hyperidrosis 

Hypertrichosis (Hirsuties) 

Ichthyosis 

Ichthyosis congenita 

Impetigo 

Impetigo contagiosa 

Impetigo herpetiformis 

Keloid 

Keratosis follicularis 

Keratosis pilaris 

Keratosis senilis 

Lentigo (Freckels) 

Lepra 

Leucoderma (Vitiligo) 

Lichen planus 

Lichen ruber 

Lichen tropicus 

Lipoma 

Lupus erythematosus 

Lupus vulgaris 

Lymphangioma 

Melanoderma lenticularis pro- 
gressiva 

Miliaria rubra 

Milium 

Molluscum (Epitheliale) con- 
tagiosum 

Morphoea 

Myoma 

Myxcedema 

Naevus fibrosus 

Nsevus- pigmentosus (Moles) 

Naevus pilosus 

Nsevus vascularis (Birth mark) 

Neuroma 



8 



LECTURES IX DERMATOLOGY. 



(Edema circumscriptum acu- 

tum 
Onychauxe 
Pachydermatocele (or Derma- 

tolysis) 
Pediculosis capillitii 
Pediculosis corporis 
Pediculosis pubis 
Pellagra 
Pemphigus 

Pemphigus neonatorum 
Phlegmona diffusa 
Pityriasis maculata et circi- 

nata (P. rosse) 
Pityriasis rubra 
Pityriasis rubra pilaris 
Pompholyx 
Pruritus 
Psoriasis 
Purpura : 

a. simplex 

b. haemorrhagica 
Rhinoscleroma 
Rosacea : 

a. erythematosa 

b. hypertrophica 
Sarcoma 
Scabies 



Sclerema neonatorum 
Scleroderma 
Scrofuloderma 
Seborrhcea : 

a. congestiva 

b. oleosa 

c. sicca 
Steatoma 
Sudamen 
Sycosis vulgaris 
Syphiloderma 
Tinea favosa 

Tinea trichophytina (Ring- 
worm) : 

a. circinata 

b. tonsurans 

c. sycosis 

Tinea versicolor (Chromophy- 

tosis) 
Trichorrexis nodosa 
Tuberculosis verrucosa cutis 
Uridrosis 
Urticaria (Hives) 
Urticaria pigmentosa 
Vaccinia 
Verruca (Warts) 
Xanthoma 
Xerosis 



Among these many skin diseases, only the following 
can be distinctly classified in groups according to the 
character of their lesion : 



CLASSIFICATION OF SKIN DISEASES. 



MACULAR SKIN DISEASES. 

Chloasma 

Erythema 

Lentigo 

Morphoea 

Nsevus simplex 

Purpura 

Scleroderma 

Chromophytosis 

Vitiligo 



PAPULAR SKIN DISEASES. 

Lichen tropicus 

Lichen acuminatus 

Lichen planus 

Lichen scrofulosorum 

Keratosis pilaris 

Acne 

Comedo 

Milium 

Prurigo 

Psoriasis 



TUBERCULAR SKIN DISEASES. VESICULAR SKIN DISEASES. 



Carbuncle 

Epithelioma 

Keloid 

Lupus vulgaris 

Molluscum 

Rhinoscleroma 

Xanthoma 



Herpes 

Sudamina 

Dermatitis venenata 

Zoster 

Impetigo contagiosa 

Dysidrosis 



PUSTULAR SKIN DISEASES. 

Acne vulgaris 

Impetigo 

Ecthyma 

Sycosis 

Furunculosis 



BULLOUS SKIN DISEASE. 

Pemphigus 

TUMOROUS SKIN DISEASES. 

Fibroma 
Sarcoma 
Carcinoma 



DIAGNOSIS OF DISEASES OF THE SKIN. 

In making a diagnosis in skin diseases a good history 
of the case must first be obtained, and then a carefuL 



10 LECTURES IN DERMATOLOGY. 

examination of the lesions presented. In obtaining this 
it would be well to follow some such systematic plan as 
here presented : 



I.- 


—HISTORY OF PATIENT. 


II. EXAMINATION OF LESION. 


I. 


Age 


i. Extent and distribution of 


2. 


Sex 


lesions 


3- 


Occupation 


2. Color of the lesions 


4- 


Previous attacks 


3. Acute or chronic character 


5- 


Time of present attack 


of lesions 


6. 


Constitutional disturbance 


4. Individuality of lesions 


7- 


Local symptoms 


5. Configuration of lesions 


S. 


Hereditability 





History of the case. The age of the patient is very 
often an important factor in making a correct diagnosis, 
for many diseases of the skin occur exclusively in children 
and others in adults. Thus, scarlet fever, chicken-pox, 
measles, impetigo, some forms of eczema, occur almost 
exclusively in children, while psoriasis, pruritis, tinea 
versicolor, epithelioma, etc., never occur in infants. 

Sex. Although sex is less important than the age in 
diagnosing skin affections it is nevertheless of some aid, 
for such a disease as sycosis occurs only in the male, while 
other affections, as epithelioma, occur more often in the 
male and lupus in the female. 

Occupation. A disease is often known by the cause 
that produces it. By ascertaining the occupation of the 
patient the cause of the disease may be determined, and 
the diagnosis made or confirmed. Thus washerwomen 
and others whose hands are frequently in water suffer 
from eczema, workers in chemicals from dermatitis, etc. 

Previous attacks. Many skin affections, especially 
those caused by the exanthematous diseases, as measles, 



DIAGNOSIS OF DISEASES OF THE SKIN. II 

small-pox, etc., a person has but once, while of other erup- 
tions, as eczema, psoriasis, etc., one attack is quite sure to 
be followed by others. Thus it is of the greatest import- 
ance to obtain the previous history of the patient. Many 
of the syphilitic lesions are so obscure that without a 
history of chancre it would be difficult to make a positive 
diagnosis, while with such a history the treatment is at 
any rate very satisfactory. 

Length of time of the present attack. By determining 
this history we arrive at the acute or chronic character of 
the eruption. Acute diseases, such as measles, erythema, 
urticaria, etc., are of short duration, lasting for hours or 
days. Subacute eruptions, as eczema, are of longer dura- 
tion and last for weeks, while in the chronic affections, as 
lepra, lupus, psoriasis, acne, etc., the eruption lasts for 
months or years. By obtaining this history many dis- 
eases may be eliminated and the diagnosis be selected 
from a few. 

Constitutional disturbance. With most of the inflam- 
matory contagious affections of the skin the constitutional 
symptoms are pronounced. In such affections as erythema 
and urticaria there is nearly always some stomach disturb- 
ance. In more chronic affections, as psoriasis and eczema, 
the general health suffers but little, while in lepra, syphilis, 
epithelioma, etc., the constitutional symptoms and general 
impairment of health form one of the marked features of 
the disease. 

Local symptoms. A snap diagnosis can frequently be 
made of a skin disease by the local symptom as repre- 
sented by the patient. Thus in psoriasis, eczema, and the 
parasitic skin diseases, itching is a constant symptom. In 
urticaria there is burning and smarting. In herpes zoster 
burning and lacerating pains, some of the symptoms being 



12 LECTURES IN DERMATOLOGY. 

almost diagnostic of the disease in which they occur. But 
if the history of the case is important, much more so is 
the personal examination of the lesion presented. 

Extent of lesion and distribution. Some skin diseases 
are limited to certain portions of the body, others have a 
predilection for particular parts, others occur on any part 
of the body, while still others extend over the whole 
surface. Thus, sycosis affects the hair follicles, acne ap- 
pears on the face and shoulders, lupus on the face, pso- 
riasis on the elbows and knees, eczema may attack any 
portion of the body, while the exanthemata may extend 
over the entire surface. 

Color of lesion. The color of the skin lesion will fre- 
quently throw much light on the diagnosis. For instance, 
the later syphilitic lesions are of copper color; the keloid, 
pinkish ; chloasma and lupus vulgaris, a yellow or reddish 
purple ; leucodcrma, a dead white, etc. 

Acute or chronic character of lesion. The appearance 
of a skin eruption will frequently show whether it is acute 
or chronic, whether on the increase or decrease, without 
obtaining a history from the patient. This is of import- 
ance, for frequently it is impossible to obtain a history, or 
else the patient may purposely give a wrong one to mis- 
lead the physician. In the acute affections we may expect 
to find the primary lesions present with more or less signs 
of active inflammation, and in urticaria, the exanthemata, 
and erythema, some acute constitutional disturbance, as 
fever, vomiting, and general malaise. In the chronic 
affections the symptoms are much less active in character; 
some of the secondary lesions are usually present with or 
without the primary ; there is frequently, especially in the 
syphilides, pigmentation of the skin, and the constitu- 
tional symptoms are seldom active although there may be, 



DIAGNOSIS OF DISEASES OF THE SKIN. 1 3 

as there is in lepra, syphilis, and cancer, great impairment 
of the general health. 

Individuality of lesions. Each separate lesion must be 
examined carefully to see of what character it partakes, 
whether the lesions are all of one kind, or multiple. It 
must not be forgotten that two or more skin diseases may 
make their appearance at the same time, or occur togeth- 
er in the same person, and although this may complicate 
matters so that the diagnosis is uncertain, still the char- 
acteristic lesions and symptoms of each are usually dis- 
tinctly present, and can be made out by careful study. 
At the New York Dispensary I have seen as many as 
seven distinct skin diseases upon the same man, each of 
them being so distinct as to be easily recognized. 

Configuration of lesions. The lesions of the skin form 
themselves often into a great many figures or patterns, 
some of them being diagnostic of the disease. When the 
patch is circular it is called circinatus, or in ring form 
annulatus, and seen frequently in syphilitic lesions and 
ringworm. If occurring in concentric rings the term iris 
is employed, as in herpes iris. When one margin of the 
lesions is elevated and sharply defined against the sound 
skin the term marginatus is applied, and occurs in ring- 
worm about the genitals. Where the lesions are winding 
or gyrate the term gyratus is used, and occurs in psoriasis 
and syphilis. Tubercular and ulcerating lesions are called 
serpiginous when they spread in a creeping manner, and 
are often syphilitic. 

Hereditability. Before leaving this subject of diagnosis 
I wish to say a few words as to the hereditary tendencies, 
or predisposition. As some skin diseases, the most com- 
mon examples being syphilis, leprosy, psoriasis, eczema, 
and scrofulosus, are undoubtedly hereditary, it is not only 



14 LECTURES IN DERMATOLOGY. 

necessary to obtain a good history of the patient, but 
often extremely important to obtain a family history as 
well. Some rare forms of syphilitic eruptions in infants 
would be most difficult to diagnose if it were not for the 
syphilitic history of the mother. 



LECTURE II. 

GENERAL THERAPEUTICS. 

Gentlemen ; 

Skin diseases so far as their treatment is concerned may 
be divided into three classes. 

First, those having a natural tendency to pursue their 
course to a final termination without any treatment what- 
soever, but are, in fact, often made worse by applications 
intended for their cure. 

Second, those cases having but little tendency to run 
a favorable course, but become chronic, extend and 
reappear from time to time, yet are cured by proper 
treatment. 

Third and lastly, those diseases ot the skin which al- 
ways terminate fatally, or last during the life of the 
patient, are not curable, but are usually relieved by treat- 
ment. 

In the first class our treatment should be directed tow- 
ard the comfort of the patient, and by wise counsel pre- 
vent the use of therapeutic measures which would retard 
rather than hasten recovery. 

In other classes of cases the therapeutic agents employed 
may be administered internally or applied externally. 
Almost all diseases of the skin require for their successful 
management external treatment, and on the other hand 
very few seem to be materially benefited by internal 
15 



1 6 LECTURES IN DERMATOLOGY. 

medication. So you can readily understand that as der- 
matologists we must deal principally with drugs which are 
used externally. The remedies which are used internally 
and have undoubtedly some value in curing or relieving 
diseases of the skin are, in the relative order of value, prep- 
arations of mercury, arsenic, iodide of potassium, cod- 
liver oil, alkalies, ergot, and quinine. 

I have not mentioned in this list tonics, which are often 
very serviceable in skin diseases by improving the general 
health, but have named only the most important drugs, 
which are known by repeated use to possess some direct 
influence on the skin lesions, tending to cause them to 
disappear. 

MERCURY. 

The value of mercury in almost all the syphiloderma is 
acknowledged by dermatologists, and it is almost wholly 
among this class of cases that the drug is now employed 
internally. Few non-syphilitic affections are benefited by 
this drug, so mercury is frequently used internally as a 
means of diagnosis between syphilitic and non-syphilitic 
diseases by those who are in doubt as to the nature of 
the disease, claiming that if the eruption is cured by 
mercury, it must necessarily have been syphilitic. This 
seems to me a very unscientific way of making a diag- 
nosis—in fact, it is very much like having some one else 
step in and make a diagnosis for you, and even then an 
uncertain one. 

There are a number of other skin diseases besides 
syphilis that are benefited by mercury, and although per- 
haps not acted upon so promptly will eventually cure the 
trouble. Mercury seems specially indicated in chronic 
papular, scaly skin diseases, as psoriasis, lichen planus, 



GENERAL THERAPEUTICS. \J 

and those tubercular skin affections as lupus vulgaris and 
scrofuloderma. 

I do not want you to understand that mercury will 
cure these diseases I have just named, for sometimes you 
may give it without any beneficial effect ; but usually 
you will find an improvement, and sometimes a cure. 

The best preparations of mercury to use are the 
iodides, and preferably the proto-iodide. Mercury may 
be given in connection with iron and arsenic, a very 
valuable solution being Donovan's solution of the iodide 
of arsenic and mercury. 

ARSENIC. 

There is no drug which has been so extensively em- 
ployed in skin diseases as arsenic. It is a custom with 
almost every physician who knows little about diseases 
of the skin to prescribe arsenic in almost every skin dis- 
ease he is called upon to treat, no matter what the lesion 
may be. Such then is the reputation of the drug as a 
specific in skin diseases, and yet no remedy is more 
abused, for its beneficial action is very limited. 

In skin diseases characterized with the formation of 
bullae arsenic is indicated, and may be given with excellent 
results. Especially is this true in acute pemphigus where 
it may be said to act as a specific. Arsenic by many is 
considered a specific also in sarcoma cutis, and it certainly 
does seem to have a marked beneficial effect in most all 
cases of this disease by retarding the development of the 
new growths, and even causing some ®f them to entirely 
disappear. 

As a general rule you may consider arsenic as counter- 
indicated in all acute affections of the skin, and indicated 
in the chronic papulo-squamous diseases, especially 



1 8 LECTURES IN DERMATOLOGY. 

psoriasis, squamous eczema, and lichen planus. Skin 
diseases in persons suffering from chronic malarial poison- 
ing may be treated advantageously with arsenic. Nine 
out of ten cases of acne are treated by the internal ad- 
ministration of arsenic, and, when occurring in anaemic 
and debilitated persons, with the greatest success ; but 
the good result is probably due to the tonic action of tin- 
drug rather than by any direct influence on the skii? 
lesion. Arsenic is best given in the form of Fowler's 01 
Donovan's solution, well diluted and after meals. It i£ 
usually necessary to give large doses, and continue it?- 
use for some time. 

IODIDE OF POTASSIUM. 

Iodide of potassium is used very frequently in skin dis- 
eases by physicians, but less frequently by dermatologists. 
Its use more often does harm than good, by its tendency 
to set up inflammatory action in the sebaceous glands. 
Skin diseases, the result of syphilitic eruption, especially 
those occurring late in the disease, are cured by the 
iodides, while scrofuloderma and lupus are undoubtedly 
benefited by its use. 

COD-LIVER OIL. 

Cod-liver oil may be employed in a large number of 
skin diseases. Hebra considered it a remedy of special 
value, and one which could be given with advantage in 
most skin diseases. Its special value is in the cutaneous 
affections of children and infants, and in the chronic skin 
diseases of adults accompanied with wasting, such as 
lupus, syphilis, scrofula, sarcoma, etc. Seborrhcea or 
greasy conditions of the skin are not counter-indications 
for its use. 



GENERAL THERAPEUTICS. 1 9 

ALKALINE DIURETICS. 

The alkaline diuretics given before meals are not only 
indicated in the more acute skin affections, as urticaria and 
erythema but also in eczema, both acute and chronic, in 
psoriasis, in lichen planus and in acne occurring in the 
plethoric. The best of these diuretics is potassium acetate, 
given in twenty-drop doses before meals, either in water 
or, if constipation exists, in the rhubarb and soda mixture. 

ERGOT. 

Ergot may be used with great advantage in acne, 
especially acne rosacea, and in all the hemorrhagic skin 
affections, especially purpura. 

QUININE. 

Quinine is curative in the neurotic skin affections, as 
herpes, and in all skin diseases complicating malarial 
poisoning. 

Phosphorus, carbolic acid, tar, ichthyol, resorcin, and 
hundreds of other drugs are given in skin diseases for 
their direct influence on the skin lesion, but only those I 
have named have stood the test of repeated trials. I do 
not wish you for one moment to think that these few 
drugs I have mentioned are the only ones you will be 
called upon to use with your patients affected with skin 
diseases, for you will frequently be obliged to treat the 
general health of your patient, and unless you do so, 
poor results will follow all your efforts. 

HYPODERMATIC MEDICATION. 

Before leaving the subject of internal medication, I 
wish to say a few words to you of hypodermic injections 



20 LECTURES IN DERMATOLOGY. 

of medicine for the cure of skin diseases. Fowler's solu- 
tion of arsenic is used with good result injected into sar- 
comatous tumors. It may be used at full strength, but 
had better be diluted with four or five times its volume 
of water. 

Mercury in various forms has been used by injection 
for the cure of syphilitic eruptions, but the pain and 
danger of producing abscesses is an objection to its use. 

It may, however, be used in infants with good result, 
or in adults where emergencies demand heroic treatment. 
The bichloride of mercury well diluted may be thus em- 
ployed, or calomel or yellow oxide may be used held in 
suspension in either water or gum arabic in the propor- 
tion of three parts to thirty, and about fifteen minims, of 
this injected at one time and repeated in five days. The 
injection should be deep in the cellular tissue, or in the 
muscles of the gluteal region. 

Pilocarpine is now used by hypodermic injection to 
stimulate the growth of the hair in alopecia, with good 
result. 

EXTERNAL MEDICATION. 

It is unfortunate that we have very few drugs which 
are specific in skin diseases — that is, in themselves have a 
direct influence in curing the disease, as mercury has in 
syphilis. In other words, we must treat the majority of 
skin diseases with external treatment, in the same way 
we treat scarlet fever or pneumonia with internal medi- 
cation. As we cannot say that this drug or that 
drug would cure pneumonia, neither can we say 
that this application or that application will cure eczema. 
We must treat very largely the symptoms, and by reliev- 
ing the conditions present cure the disease. We must 



GENERAL THERAPEUTICS. 21 

therefore divide our external remedies into groups, ac- 
cording to their physiological or mechanical actions. 
Thus, they may be either soothing, astringent, stimulating, 
protective, drying, antipruritic, parasitic, antiseptic, or 
specific. 

To be in accord with the more recent progress of der- 
matology we must understand the various methods of 
applying medicaments to the skin, and know what proper- 
ties the medicines or the bases with which they are com- 
bined must possess to obtain the best results. 

First. The drug must be either in soluble form, or so 
minutely divided as to pass into and through the outer 
layers of the skin. 

Second. The preparation must be protective against 
external influences, especially where the outer skin is 
broken or removed. 

Third. The base should be readily soluble to carry the 
drug with it. 

These general rules just mentioned are not without ex- 
ception, but they answer very well for the treatment of 
most skin diseases. 

Drugs for external application may be used in the form 
of ointments, plasters, powders, lotions, baths, caustics, 
and soaps. 

OINTMENTS. 

The best success in treating skin diseases is obtained 
by the use of ointments. In many respects these are 
disagreeable and nasty means of applying treatment, soil- 
ing the patient's clothing and making them feel very un- 
comfortable and dirty, but nevertheless efficacious. They 
are usually made by incorporating the drug or drugs to be 
employed in some fatty base, as lard, vaseline, or lanoline 



22 LECTURES IN DERMATOLOGY. 

Benzoitic lard is usually used for the bases of all oint- 
ments, as it keeps nicely, is about the right strength, is 
protective, is quite readily absorbed by the skin, and is 
cheap. 

Lanoline, a fat made from the oily matter obtained 
from sheep's wool, may be more readily absorbed by the 
skin than is lard, but in other respects it is inferior. 

Vaseline is cheaper than lard, keeps longer without 
spoiling if pure, but is not readily absorbed, and if not 
properly prepared contains impurities which are very irri- 
tating to many skins. In parasitic skin affections vase- 
line seems to act as itself a parasiticide, so that I should 
advise you to use it as a base for your ointments in all 
skin affections of this nature. Remember that mercury 
and vaseline do not mix well together. 

Ointment mulls. Unna has overcome the objectionable 
features of ointment applications to a great extent by 
leaving the ointment spread on mull so that it is really in 
form of a plaster and applied as such. 

Ointment of the water of roses of the U. S. P. is some- 
times used as the base for ointments, and Dr. Bulkley 
considers it the best. Where protection is required to the 
skin it is certainly a very valuable preparation to use as a 
base for other ingredients. It is very important that you 
should see your ointment is free from any coarse parti- 
cles, for frequently poor results of treatment are due to 
poorly prepared ointments. In 1891 two excipients were 
produced which very nicely take the place of fatty sub- 
stances in making ointments. These are called bassorin, 
which is made from gum tragacanth, and plasmcnt, made 
from Irish moss. They are easy and simple in applica- 
tion, requiring only to be spread upon the skin with the 
finger or a brush. They dry in the space of a few minutes 



GENERAL THERAPEUTICS. 2$ 

if so applied, adhere closely, and do not rub off and soil 
the linen, but form a flexible coat which does not inter- 
fere with the movements of the body. When its removal 
is desired the preparation can be washed off with a little 
water, or a damp cloth or sponge. They remain in situ 
without change for a variable length of time, depending 
upon the condition of the surface on which they have 
been applied. 

With these pastes almost any drug can be incorporated ; 
those which exist in the form of powders, or in solid forms 
in any amount desired ; the tars, ichthyol, and oily sub- 
stances in smaller percentages, but sufficient for all 
practical purposes. 

The properties possessed by these pastes render them 
superior to ointments for the reasons, among others, that 
it is difficult to keep the latter in constant contact with 
the diseased surface ; that salves soil and stain the linen, 
and offer such other objectionable features as greasiness, 
risk of becoming rancid, etc., to say nothing of the dis- 
comfort entailed upon the patients using them. 

GELATOLE OINTMENTS AND PLASTERS. 

As most of these drugs are only incorporated in the 
fatty bases used in preparing the ointments, it has been 
thought that better results could be obtained by having 
the drug in solution. To this effect gelatole ointments are 
now made by first dissolving the drug in a suitable sulpho- 
oleate salt, combining it with a fatty base, and adding 
enough gelatine to give consistency and form a protective 
film. A wide range of drugs may thus be brought into 
condition to readily penetrate the skin. 

The unofficial gelatole plasters are the ones now some- 
times used in the place of ointments. These are prepared 



24 LECTURES IN DERMATOLOGY. 

in the same way, by dissolving the drug to be employed 
in sulpho-oleate of sodium (a solvent for at least a small 
percentage of almost any drug), and combining with a 
fatty base. Gelatine is then added to give strength, and 
the mass spread on cloth either pervious or impervious as 
desired, in the form of a plaster ready to be applied to 
the skin lesions. 

The action of these preparations when applied to the 
skin is largely due to their affinity for liquids, whereby 
the layer of air upon the surface of the skin is displaced, 
and a close contact established between the compound 
and the glands and follicles, and absorption rapidly fol- 
lows. By the slight saponifying of the sulpho-oleate acid 
the fatty exudatets of the skin, dirt, and other matters, 
are emulsified, and their power to prevent absorption 
removed. 

Some druggists keep these plasters and ointment mulls 
already prepared, and they are named from the drug dis- 
solved in them. Thus, you may ask for a 5 per cent, salicylic 
gelatole plaster, or an oxide of zinc ointment mull. The- 
oretically these plasters should be all that is desired for the 
treatment of skin diseases, for the full and continued action 
of the combined drug is fully presented to the diseased 
surface. They are clean, adhesive, light, applied easily 
and do not have the objectionable feature of extreme 
adhesiveness — or the complete envelopment of the drug 
by the base that prevents the use of resinous or rubber 
plasters in dermal practice. 

Practically these plasters have not taken the place of 
ointments. They are expensive, not always easy to ap- 
ply, are not adapted for use where a large extent of sur- 
face is to be treated, often produce more irritation of the 
skin than ointments, and in many cases the sulpho-oleate 



GENERAL THERAPEUTICS. 2$ 

of sodium will not dissolve a large enough percentage of 
the drug to be serviceable. Where small areas of sur- 
face are to be treated, and you wish to get a continued 
and penetrating action of the drug, as in cases of scaly 
and thickened lesions of the hands and feet, these plasters 
are very serviceable. 

GLYCO-GELATIXES. 

These are composed of a combination of glycerine and 
gelatine with oxide of zinc or water, in nearly equal propor- 
tions. Nearly all the medicaments used in the treatment 
of diseases of the skin are miscible in proportion from 5 
to 15 per cent, and are added as required. The method 
of application of this form of dressing is excessively sim- 
ple. The solid glyco-gelatine is melted in a hot-water 
bath. It is then applied with a paint brush to the affected 
region, and dabbed over immediately after with a roll of 
absorbent cotton. Thus a sort of skin is formed, which 
acts as a protector and as a medium, by which the medi- 
caments may be kept in constant contact with the skin. 
Besides this, it acts beneficially by its slight compressing 
effects, producing a localized anaemia, also favoring the 
absorption of inflammatory products. 

TRAUMATICIN AND COLLODION. 

Liquor guttapercha^ (traumaticin) and flexible collo- 
dion are sometimes used as excipients for drugs. They 
give us cleanly fixed dressings, which exert a certain 
amount of pressure on the skin that is very useful in 
many cases where we have chronic thickening of the skin, 
as in psoriasis ; but in acute diseases when there is more 
or less exudation they cannot be used. I warn you to be 



26 LECTURES IN DERMATOLOGY. 

very careful, in making applications to the skin, never to 
confine sero-purulent or purulent secretions under your 
dressings, for it always causes mischief. I have frequent- 
ly seen deep ulcerations of the skin following applications 
of collodion and other impermeable substances in skin 
diseases accompanied with purulent or sero-purulent exu- 
dation. 

LOTIONS. 

Lotions, although not as important as ointments in the 
treatment of skin diseases, play an important part and 
should be carefully prepared, so that their ingredients are 
thoroughly pulverized and mixed. Lotions may be 
applied occasionally to the diseased skin, or they may be 
kept continually in contact by means of thin cloth wet in 
the solution, but not covered with oil silk as they then 
have a poulticing action. Glycerine is usually added to 
the lotion as a demulcent, but you must remember that 
some skins cannot stand glycerine, it acting as an irritant. 
Lotions are more cooling and astringent than ointments, 
and are easier to apply to the face and scalp. The same 
drugs may be used in the same proportion, and to fulfil 
the same indications in lotions as when used in the form 
of ointments 

POWDERS. 

Powders are more frequently used in skin diseases by 
the laity than by dermatologists. When used they should 
be very fine and free from any gritty particles. Care 
must be taken that powders be not allowed to cake upon 
the skin, or to be worked into a paste. If in this condi- 
tion they frequently do more harm than good. Powders 
are more drying than other forms of application to the 
skin, and seem to possess a cooling influence on inflamed 



GENERAL THERAPEUTICS. 2J 

skins, and are therefore indicated in erythematous and 
vesicular eruptions. Among the powders used for such 
conditions may be mentioned buckwheat flour, calamine, 
fuller's earth, lycopodium, and magnesia. 

In case there is a tendency to the formation of pustules 
salicylic acid or boric acid may be added as an anti- 
septic in acute exudative inflammations of the skin, as 
weeping eczema. These powders may be used for their 
drying and astringent properties, but care must be exer- 
cised to prevent the caking of the powder and the reten- 
tion of the secretions under them. 

BATHS. 

Hot- or cold-water baths are occasionally used as a 
remedy in skin affections, but their use is very limited. 
In chronic inflammations of the skin where there is much 
crusting and scaling, these crusts and scales may be 
removed by continual applications of hot water. Hot 
water, by its relaxing effects on the tissue, is frequently 
used with good effect to hasten the resolution and ab- 
sorption of inflammatory thickenings in the skin. You 
should remember, however, that water in acute inflamma- 
tion of the skin, especially accompanied with exudations 
as in eczema, is counter-indicated. Turkish and Russian 
baths you will seldom prescribe for your patients. 

Medicated baths should be taken hot or tepid, the 
patient remaining in the bath from ten to thirty minutes. 
Among the best medicated baths are the bran, alkaline, 
and the carbolic acid, and sulphur. 

Bran baths are especially serviceable in all cases requir- 
ing a soothing application to the skin, and where the 
subjective sensations are itching, burning, or pricking, 
such as occur in erythema, exanthemata, urticaria, sub- 



28 LECTURES IN DERMATOLOGY. 

acute or chronic eczema, psoriasis, etc. A pound of bran 
may be added to a bath of fifteen gallons of tepid water. 
It may be simply mixed with the water, or confined in a 
cheese-cloth bag soaked in it. Starch or gelatine is 
sometimes used in place of bran in about one half the 
quantity. 

Alkaline baths are used for very many of the same 
conditions as the bran baths, but are especially service- 
able in the scaly skin diseases. The water may be first 
made demulcent by the use of bran or starch, and then 
half a pound of washing soda added to the bath. 

Carbolic acid baths, from four to eight ounces to fifteen 
gallons of water, are especially serviceable as antipruritic 
remedies in the conditions of the skin already mentioned, 
and may be used without fear of absorption if the skin is 
not excoriated. The bath has undoubtedly some anti- 
septic properties, and you will find it very serviceable in 
the parasitic skin affections, and in the exanthemata when 
desquamation is progressing. 

Sulphur baths are sometimes employed for the cure of 
parasitic skin affections, especially scabies, and, used as a 
help to other treatment, may be highly recommended. 
Two ounces of precipitate of sulphur, and one ounce of 
the hyposulphate of sodium may be added to fifteen gal- 
lons of water. In seborrhceal affections and when the 
skin is very oily these baths are serviceable. 

CAUSTICS. 

Caustics are not often required for the treatment of 
skin diseases, except in cases of lupus and epithelioma 
and naevi. Those most frequently employed are arsenic, 
chloride of zinc, nitrate of silver, carbolic acid, and sodium 
ethylate. 

When arsenic or chloride of zinc is employed, it is best 



GENERAL THERAPEUTICS. 29 

mixed with equal parts of starch or pulverized acacia, 
and enough water added at the time of using to make a 
thick paste. This is to be kept on the diseased surface 
for twelve hours or more, and then poultices applied until 
the slough separates. 

Nitrate of silver is especially serviceable in the treat- 
ment of tubercular forms of lupus, each tubercle being 
punctured by the solid stick sharpened at the point. 

Carbolic acid is a superficial caustic usually applied with 
a brush, and especially useful in the treatment of ery- 
thematous forms of lupus and mucous patches and ring- 
worm. 

Equal parts of ethylate of sodium dissolved in alcohol 
is the best superficial caustic in the treatment of capillary 
and pigmentary nasvi. The solution should be applied to 
the naevi with a brush. 

Tincture of iodine is a superficial caustic to use in cases 
of ringworm, either of the body or of the scalp. 

SOAPS. 

Soaps are of two kinds. The hard or soda soap, and 
the soft or potash soap. 

Hard soap is neutral in reaction, and used chiefly for the 
purpose of ablution. 

Soft soap is decidedly alkaline in reaction, due to an ex- 
cess, of the potash present, and has a much larger thera- 
peutical action. It is usually dissolved in alcohol in the 
form of tincture of green soap. It has the physiological 
property of cleansing the skin, removing the oil or grease 
from its surface, causing a superficial destruction of the 
horny layer of the epidermis, acting as a direct stimulant 
or irritant to the skin. Its therapeutic properties are 
especially marked in treatment of the chronic scaly 
diseases of the skin. 



30 LECTURES IN DERMATOLOGY. 

Besides these two varieties of soaps we have a large 
number of medicated soaps made by adding some drug to 
a hard soap. Most of these preparations are worthless 
things. The best of them are the sulphur, corrosive 
sublimate, tar, ichthyol, and carbolic acid soaps. 

These medicated soaps should never be relied upon in 
the treatment of skin diseases, but are sometimes useful 
when used as adjuncts to other forms of treatment. Thus, 
if you are treating a case of psoriasis in which tar is indi- 
cated, it would be well to tell your patient in washing to 
use tar soap. 

In conclusion I would again warn you to be careful, in 
making applications to the skin, never to confine purulent 
secretions under your dressings, for it always causes 
mischief. 

INSTRUMENTS USED IN DERMATOLOGY. 

You will find it convenient in the treatment of skin 
diseases to possess the following instruments, besides 
those usually found in pocket-cases. 

I. Small and medium-sized dermal curettes for remov- 
ing new formations in the skin. 

II. Small and medium-sized dermal burrs for destroying 
diseased sebaceous glands and removing lupus nodules. 

III. Single and multiple scarificators for treating naevi, 
lupus, and acne rosacea. 

IV. Epilatory forceps. 

V. Comedone extractors for treatment of acne. 

VI. Small and medium-sized dermal punches for re- 
moving small epithelioma, warts, moles, powder grains, etc. 

VII. Dermal spear for opening skin abscesses and for 
puncturing papulo-pustular lesions, especially those occur- 
ring in acne vulgaris. 

VIII. Galvano-cautery battery with electrolysis needles 
for removing hairs and for treatment of naevi. 



LECTURE III. 

ACNE, ALOPECIA, AND ALOPECIA AREATA. 

Gentlemen : 

Having gone over with you in a general way the classi- 
fication, diagnosis, and thereapeutics of skin diseases, I 
will now call your attention to the consideration of some 
of the most common skin affections. 

ACNE. 

Probably among the first of the skin diseases which 
you will be called upon to treat will be acne. This is the 
most common of all skin diseases, and there are but few 
people in our climate who have not at some time or 
another suffered more or less with it. 

Pathology. The disease is an inflammatory one, and has 
its seat in the sebaceous glands and follicles of the skin, 
and not only involves the gland structure but the tissue 
about it. The first stage in the disease is a retention of 
the glandular secretion, which is followed by a hyper- 
aemia and cellular exudation in and about the walls of the 
glands, which usually goes on to suppuration, and may 
be so extensive as to result in scar formation. 

Etiology. The causes for acne are numerous, and may 

be constitutional or local. There is no question that 

there is often an hereditary disposition, making certain 

persons very susceptible to the disease. It occurs about 

31 



32 



LECTURES IN DERMATOLOGY. 



equally in the sexes, most frequently making its appear- 
ance about the sixteenth year. It is more common in 
persons with fair skin than those with dark, although 
some of the worst attacks occur in brunettes. Among 
the most common causes are functional derangement of 
the stomach, bowels, and generative organs. 

Diseases of the blood, as anaemia, chlorosis, and general 
cachexia produce the worst forms of acne, known as acne 
cachecticorum. 

Medicines, especially the iodides and bromides, fre- 
quently are the direct cause of the disease, producing as 
one of their physiological effects inflammation of the 
sebaceous glands. Exposure of the skin to certain irrita- 
ting influences will frequently produce acne, as decided 
and sudden changes of temperature, and the application 
of certain substances, as tar. 

Symptoms. Acne usually shows itself in the form of 
either papules, tubercles, or pustules about the opening 
of the hair follicles. All three of these lesions exist 
together, but usually one or the other is predominant, 
and the disease is then called either papular, pustular, or 
indurated acne. These lesions usually exist in all periods 
of development, some of them disappearing as others are 
making their appearance. The symptoms which usually 
attract the patient's attention when a new lesion is ap- 
pearing are first a hyperaemic spot on the skin, then a 
little, hard, shotty nodule felt in or under the skin, and 
accompanied by pain on pressure over the spot. Within 
twenty-four hours the lesion becomes distinctly papular, 
raised above the skin, and surrounded by an inflamma- 
tory areola. The papule remains in this condition for a 
variable length of time. It may within a few hours sup- 
purate, a papulo-pustule forming, which either ruptures 



ACNE. 33 

or dries up, or it remains as a papule for two or three 
weeks and is gradually absorbed. When the inflamma- 
tion is deeply seated in the glands suppuration may go 
on for days before the pus reaches the surface. In these 
cases the suppuration usually extends to the surrounding 
cellular tissue, occasioning considerable swelling and pain. 
This condition is frequently spoken of as a blind boil, but 
is more properly a cutaneous abscess, and usually results 
in the formation of scar tissue. The affected skin in 
many cases is oily and shiny, and in nearly all cases pre- 
sents many black-heads or comedones, which I will speak 
of at another lecture. The number of acne lesions 
present at one time varies considerably. They seldom 
appear in groups, but often in crops, several making their 
appearance at one time. They may occur on any portion 
of the body except the palms of the hands or the soles 
of the feet, but have a decided preference for the face, 
shoulders, back, and buttocks. Acne leisons may disap- 
pear entirely or result in atrophy of the skin, in hyper- 
trophy of the glands and tissue about them, or in the 
production of scar tissue. 

Diagnosis. The diagnosis of acne is seldom difficult. 
The only diseases with which it is liable to be confounded 
are small-pox, papulo-pustular eczema and syphilis, 
sycosis, and rosacea. For these differential diagnoses of 
acne and other skin diseases I would refer you to a little 
work which I have written upon this subject, entitled 
Differential Diagnosis of the Diseases of the Skin. 

Treatment. The treatment of acne, however, requires 
for its successful management both internal medication 
and external applications. The cause of the disease 
should first be ascertained if possible, and treatment 
directed towards curing or relieving it, for otherwise if 



34 LECTURES IN DERMATOLOGY. 

the cause still exists and your remedies are employed 
only on the external lesions, you cannot hope for a per- 
manent result. In almost every case of acne the diet 
should be carefully regulated. In the cachectic a more 
generous diet is required that when acne occurs in the 
full-blooded. In all cases patients suffering from acne 
should not eat hot breads, pickles, spices, cheese, pastry, 
nuts, or candy ; nor drink coffee, chocolate, or other 
stimulating drinks. Alcoholic liquors of all kinds, ex- 
cept in the cachectic cases, should be prohibited. The 
bowels should be kept very thoroughly open by the use 
of hot water taken before meals, and if necessary sprudel 
salts or hunyadi water before breakfast. 

Besides the internal remedies which may be required 
for the treatment of the functional disturbances or of the 
cachexia accompanying the acne, certain drugs seem to 
possess a greater or lesser influence independent of the 
local skin treatment. Arsenic, perhaps, heads the list of 
valuable internal remedies, and in many cases it does seem 
to be especially beneficial. You will find that it acts better 
in those cases that have lasted for a long time where the 
induration is marked, where the disease is very extensive, 
and where the blood is in a very poor condition. Iron 
and cod-liver oil are also indicated in these sort of cases. 
Donovan's solution of the iodide of arsenic and mercury 
has proved a better agent in many hands than other 
preparations of arsenic, probably on account of the mer- 
cury it contains, although Fowler's solution is the prep- 
aration usually given. Sulphur and molasses is an old- 
time remedy in acne, especially useful in those cases 
where the bowels are sluggish, and where pustulation is 
extensive. The sulphide of calcium is now extensively 
used to lessen the amount of pustulation, and given in 



ACNE. 35 

one-tenth-of-a-grain doses every two hours, seems to act 
very much more satisfactorily than if given in larger doses 
less frequently. Acne occurring in the plethoric is fre- 
quently greatly benefited by the use of sulphur spring 
waters. In the papular form of acne, glycerine given in 
tablespoonful doses two or three times a day seems to 
hasten the resolution of the papules and prevent their 
further development. 

Local treatment. There are three drugs that I can 
recommend to you most highly in the local treatment of 
acne. They are sulphur, mercury, and resorcin ; but you 
will get very little good result from their use if you do not 
employ them in a scientific manner. I have never seen a 
case of acne in which very hot water was not of decided 
benefit if used thoroughly. By thoroughly, I mean for 
half an hour three times a day ; but cold water, or luke- 
warm water, should never be used unless necessary. If 
there is but little oiliness of the skin, a very satisfactory 
treatment consists in the use of hot water for half an hour 
three times a day, and then applying the following lotion : 

5 Resorcini 3 ss 

Hyd. chlor. corr. ...... gr. i 

Glycerini 3 ii 

Aq ad 3 ii 

Sometimes the glycerine, even in small quantities, will 
not be well borne by the skin, and you will have to leave 
it out of the lotion. If the disease is very sluggish and 
slow to respond, the following ointment 

5 Resorcin 3 ss 

Ung. hyd. ammon., 

Ung. aq. rosse aa § i 

m 



36 LECTURES IN DERMATOLOGY. 

may be applied at night. If this treatment causes a der- 
matitis, the application may be made less severe. Where 
the face is specially oily and greasy, sulphur lotions and 
ointments are better than the mercury. Such a lotion 
may be prepared as follows: 

5 Gum. tragacanth gr. v 

Camphor gr. x 

Sulphur sub 3 ii 

Aq. calcis ad 3 ii 

This is very serviceable to use two or three times a day after 
the hot-water applications. Do not use the sulphur and 
mercury preparations together on the face, for a chemical 
reaction will take place, staining the skin. 

In chronic, indolent cases that do not respond to treat- 
ment, where the skin is greasy and muddy-looking and 
the circulation sluggish, it is often necessary to stimulate 
the skin pretty thoroughly and get up some reaction be- 
fore a cure is effected. To do this, nothing is better than 
to scrub the face every few days with the tincture of green 
soap, together with the frequent use of the following 
lotion : 

J} Pot. sulphuret 3 i 

Aq ad I ii 

Solve et adde solutionem subquentem : 

Zinc sulph 3 i 

Aq ad § ii 

One word in reference to the surgical treatment of 
acne. The contents of all comedones should be ex- 
pressed. All pustules should be freely opened and their 
contents squeezed out ; the deep collections of pus should 
be evacuated by a deep incision with the dermal spear, 
which should be turned round a few times in the skin to 



ALOPECIA. U 

destroy the glandular structure, otherwise you may have 
a collection of pus forming again in the same location. 
These little surgical operations should be done before the 
hot water is applied, for the bleeding is then encouraged, 
which is beneficial. 

ALOPECIA. 

The next subject to which I call your attention is in- 
teresting to us all, but evidently to some more than others 
for personal reasons. Although baldness is much more 
common in the male sex, it is none the less noticeable, for 
woman's uncovered head is usually covered, thereby not 
attracting attention. 

Since that terrible punishment received by the children 
who gave Elisha the unasked for advice to " go up, thou 
bald head," we have been accustomed to look upon bald 
heads with reverence, and as a sign of old age and natural 
decay ; but now times have changed, and even ballet 
dancers are apt to look down upon them. In the past 
few years, alopecia occurs so frequently in comparatively 
young persons that it may be considered as a disease when 
occurring in those under forty years of age. That a bald 
head is not a desirable possession is evidenced by the 
enormous sale of nostrums warranted to restore the natural 
covering to the scalp. 

To every hair is given a length of life varying from 
four months to four years, and it is estimated that the 
daily average loss of hair from a healthy scalp varies from 
13 to 200. In the natural condition of the scalp, every 
hair which dies is replaced by another that usually grows 
from the same papilla, but sometimes from a new papilla 
developed by the side of the old one. If this growth of 
hair did not take place, every one would be bald within 
four years. 



38 LECTURES IN DERMATOLOGY. 

These new hairs should be the same size as the old ones, 
and have the same length of life. The thicker the hair, 
the longer its life, so if the new hairs which make their 
appearance are smaller in calibre than the old ones, it is 
a pretty sure indication of approaching baldness. 

The term alopecia is a very general one, and should be 
used to describe a symptom rather than a disease. Just 
as we use the term headache to designate the symptom 
of a disease, so should we speak of alopecia as a symptom 
present in certain affections of the scalp. 

You can no more cure the diseased condition of the 
scalp by simply treating the symptom alopecia, than 
you can cure pneumonia or typhoid fever by remedies 
used to lessen the headache. 

There are so many varieties of alopecia, each variety 
depending upon different causes, with different symptoms, 
and demanding different treatment, that I will only have 
time to call your attention to the most important disease 
of the scalp which is accompanied by baldness — namely, 
seborrhoea. To perfectly understand how a seborrhcea of 
the scalp will result in alopecia, it will be necessary for me 
to call your attention to the very close anatomical and 
physiological relation between the hair follicles and the 
sebaceous glands. 

Each hair follicle may be considered as a prolongation 
downward of the epithelial layer of the skin into the 
corium, which is its deepest layer. In the bottom of the 
sac thus formed the fibrous elements of the corium rise 
and form a papilla, which is called the hair bulb, and from 
which the hair is supposed to take its growth. On either 
side of each hair follicle thus formed is situated a seba- 
ceous gland with its duct opening directly into the fol- 
licle, so that the secretion from such glands finds its way 



ALOPECIA. 39 

to the surface of the skin through the mouth of the hair 
follicle. The secretion from these glands supplies pabu- 
lum to the growing hairs, thereby nourishing them, so you 
can readily understand from these close relations existing 
between the hair follicles and the sebaceous glands that 
any disease, or even disturbance of function, of these 
glands must necessarily, if long continued, affect the 
growth and condition of the hairs. 

There are several forms of seborrhcea which may result 
or terminate in alopecia, but there is one variety which, 
from its great frequency of occurrence, its insidious man- 
ner of approach, the apparent insignificance of its early 
symptoms, and its certainty of termination in permanent 
baldness if not properly managed, is a disease of much 
importance, and the only one which I will speak of this 
evening. The disease which I refer to is termed alopecia 
furfuracea, or eczema seborrhoicum of the scalp, also 
sometimes called alopecia pityroides, or dandruff. 

The disease always begins in the sebaceous glands as a 
fatty, metamorphosis of the glandular cells. This degen- 
eration extends into the hair follicles, which eventually 
results in an atrophy of the hair bulb and a permanent 
loss of hair. Of late the opinion is gaining ground that 
alopecia furfuracea is a contagious disease, and the ex- 
periments of Lassar and Bishop would seem to prove this. 

They have succeeded in producing typical attacks of 
this disease in guinea-pigs by rubbing into their backs a 
pomade composed of the scales taken from the head of a 
student suffering from dandruff. A number of observers 
have found micro-organisms present in the scales pro- 
duced in alopecia furfuracea, but it is not absolutely 
demonstrated that these parasites are the direct cause of 
the disease. 



40 LECTURES IN DERMATOLOGY. 

Symptoms. The disease usually begins between the ages 
of fifteen and twenty-five years, and the first symptom 
noticed is dandruff. In the beginning this desquamation 
of fine, branny scales from the scalp is so slight as to pass 
unnoticed, but after a time they become so abundant as 
to fill the hair and fall over the clothing. All parts of 
the scalp are not equally affected, the disease appearing 
most markedly about the edges of the hair and on the 
vertex of the head, sparing the occiput and sides. Ac- 
companying this desquamation there are few if any sub- 
jective sensations attracting the patient's attention to the 
diseased condition of the scalp, a pruritus or itching of 
greater or less severity being the only symptom present. 
Sooner or later, however, the patient will notice a con- 
stantly increasing number of hairs combing out, and that 
loose hairs will be found on his clothing during the day, 
and on the pillow in the morning. At first there does 
not seem to be any thinning of the hair, as each hair is 
reproduced, but it will be noticed if a careful examination 
is made, that the new hairs are smaller in calibre, which 
is a pretty sure sign that an atrophy is already taking 
place in the hair papilla. About a year or more after the 
disease is first noticed a marked thinning of the hair will 
be found, usually beginning in two spots, one just back 
of the anterior border of the scalp, and the other near 
the vertex. This is the beginning of the end. Unless 
proper treatment is begun at once, " Good-bye, fond 
hopes of future greatness," for there will soon be left no 
hair (heir) to the crown. 

Treatment. Now for a few words regarding the treat- 
ment of this affection. As the skin is in an apparently 
healthy condition under the scales, it seems a very easy 
matter to remove these scales with soap and water or with 



ALOPECIA. 41 

oil ; but, unfortunately, the removal of the scales in no 
way removes the disease, as they will form again in even 
greater abundance in a few days, sometimes in a few 
hours after they are removed. The remedies which are 
recommended and advertised for the cure of this affection 
are only exceeded in number by those given for the relief 
of the vomiting in pregnancy. The question then arises, 
which of these remedies are we to use, and how are they 
to be applied? If you will take your Bible and read the 
twenty-third and twenty-fourth verses of the second chap- 
ter of II Kings, you will find when Elisha had his atten- 
tion attracted to his bald head he immediately looked 
around for some means of relief. He found that bears 
afforded a remedy which was wonderfully and rapidly 
effectual, for we do not hear of any further reference made 
to his bald head. 

Since then " bear's-grease " has been one of the many 
remedies applied to the scalp for the cure of alopecia. It 
acts well, especially with children, to prevent baldness. 
Some dermatologists claim that as the original prescrip- 
tion called for only the she bears, this preparation should 
be made from the female animal. The importance of 
this, however, I think is doubtful. 

Of late years we have found other agents acting to 
better advantage. The scientific treatment of the dis- 
ease differs somewhat according to the extent to which it 
has progressed. If we see the disease in its early stages 
when the only symptom is dandruff, and when the loss of 
hair is very little, if any, we can do a great deal in the 
way of prophylactic treatment. 

In the first place, the constant application of water to 
the scalp is bad. It undoubtedly tends to produce dan- 
druff, and if the disease already exists it always aggra- 



42 LECTURES IN DERMATOLOGY. 

vates it. The same is true of irritating applications to 
the scalp, such as tincture of cantharides, capsicum, and 
all strong alcoholic preparations, for they not only tend 
to set up an inflammatory condition, but by dissolving 
the natural oil of the skin, produce a dryness of the scalp 
which in the end does more harm than good, in fact may 
be the direct cause of the disease. 

The hair should be shampooed once in ten days to two 
weeks with the yolks of three eggs beaten up with lime 
water. After thoroughly rubbing this into the scalp, it 
should be washed out with a solution of borax in hot 
water, the hair thoroughly dried, and the following oint- 
ment rubbed into the scalp and allowed to remain over- 
night : 

5, Pilocarpin. hydrochlor 3 ss 

Vaselin 3 v 

Lanolin § ij 

Ol. lavandulae gtts. xv 

m 

In the morning, after the hair is thoroughly rubbed 
dry, its greasy condition will not be noticed. Moistening 
the hair every day with water will do no harm if neces- 
sary to keep the hair smooth, but daily sousing of the 
hair should be prohibited. Deep brushing of the hair 
every day with a long-bristled brush, stiff enough to warm 
but not scratch the scalp, is stimulant enough for a healthy 
scalp. 

If we do not see the patient until the hair has already 
begun to fall out to a considerable extent, a different 
plan of treatment is to be recommended. Once in every 
five days to a week the patient should take a shampoo, 
using the tincture of green soap to form a lather ; after 



ALOPECIA. 43 

thoroughly drying the hair, a pomade, as just recom- 
mended, is to be thoroughly rubbed into the scalp and 
allowed to remain overnight. In the morning this should 
be washed out with the tar soap, and the following lotion 
rubbed into the scalp : 

^ Hydrarg. chlor. corros gr. iv 

Resorcin 3i 

Aquae destil § iv 

TTl 

This lotion is to be applied to the scalp night and 
morning, rubbing it well in about the roots of the hair 
with a small sponge. Usually in three or four weeks a 
marked improvement will be noticed by the absence of 
dandruff and the hair no longer falling out. As the im- 
provement continues the treatment may be less vigorous. 
The shampoo may now be used once in ten days or two 
weeks, and the lotion applied only at night ; but treat- 
ment should be continued for at least six months. Re- 
lapses are very common, and especially so if all treatment 
is discontinued too early. After the hair has stopped 
falling out, you may find that the new hairs which replace 
those that were lost are weak and need stimulation. There 
is but one drug, taken internally, which seems to possess 
the power of stimulating the growth of the hair, and that 
is pilocarpin. It must, however, be taken in quite large 
doses to have an effect, and even then it is often disap- 
pointing. In some cases better results are obtained in 
giving it by hypodermic injection. 

Externally there are many irritant applications to the 
scalp which are recommended to stimulate the growth of 
the hair. If these applications are used while the sebor- 
rhcea is still present, only harm can come by irritating a 



44 LECTURES IN DERMATOLOGY. 

scalp which is already inflamed ; but if the disease is first 
cured, then such applications may be used with advan- 
tage. The following is the one I usually recommend to 
stimulate the growth of the lanugo hairs after all traces 
of the seborrhcea have disappeared : 

5, Tine, cantharides, 
Tine, capsici, 
Tine, nucis vomicae, 

Ol. ricini aa § ss 

Aquae coloquiesis, or bay rum . . ad § iv 

m 

This lotion may be rubbed into the scalp every night 
for several weeks, and then continued less frequently for 
several weeks longer. 

In the third stage of the disease, when baldness has 
fairly won the crown, do not despair. Your work is not 
yet done. You may somewhat dim its shining glory still 
by one more prescription — for a wig. 

ALOPECIA AREATA. 

There is another form of alopecia to which I would call 
your attention, and that is alopecia areata. 

Cause and Pathology. This disease has been variously 
regarded by dermatologists as the result of perverted en- 
ervation, a tropho-neurosis, or a parasitic skin affection. 
If the hairs be examined microscopically, they will be 
found to terminate at the root abruptly in a club shape, 
the hair bulb being contracted and atrophied. The shaft 
of the hair near its free extremity will be found swollen, 
and then tapers into a broken extremity. These condi- 
tions are all due to the fact that the hair does not receive 
its proper nourishment from the papillae. The lesions 



ALOPECIA AREATA. 4$ 

seem limited to the hair, for besides the pale, atrophic 
condition of the affected area, the skin and its glandular 
appendages seem normal. In some cases there is found 
a micro-organism, which has been considered by many 
observers as the cause of the trouble. 

I can advance very few arguments to prove the correct- 
ness of my opinions, but personal observations, from a 
purely clinical standpoint, convince me that I have seen 
but one form of alopecia areata, and that is the neuro- 
pathic. If the disease is parasitic we could expect to find 
it contagious, but I have yet to see one case where a 
careful investigation of either the history or circumstan- 
tial evidence surrounding it would point toward its con- 
tagious nature. On the other hand I have found in the 
great majority of cases evidences of well-marked nerve 
disturbance in the affected area. I have one patient un- 
der observation at the present time in whom the disease 
was preceded by the most frightful attack of tic douleureux 
that I have ever seen. A few days before each patch of 
alopecia makes its appearance this woman will suffer the 
most agonizing neuralgic pains in the area where the 
lesion is about to form. Several of these patches have 
made their appearance from time to time, and were 
invariably preceded by these sharp neuralgic pains. 
In almost all patches of alopecia areata careful examina- 
tion will disclose some nerve disturbance in the affected 
area. Subjective sensations as tingling, formication, or 
itching are not uncommon, while a careful examination 
by the aesthesiometer will show that there is usually some 
hyperesthesia or anaesthesia of the skin as compared with 
a symmetrical area on the opposite side of the body. 
But not only does this tend to prove the neuropathic form 
of the disease, but the so-called nerve tonics, especially 



46 LECTURES IN DERMATOLOGY. 

arsenic, phosphorus, and strychnine, if used early in the 
disease and pushed to their therapeutical limit will in 
many cases prevent the spread of the disease and hasten 
the return of the hair. 

The only one argument which I can hold forth in sup- 
port of the parasitic nature of the disease is the good 
effect resulting from the local use of such germicides as 
iodine and carbolic acid ; but I believe these agents act 
not by virtue of their antiparasitic properties, but by 
stimulating the sensitive nerves to better conductivity, 
which in turn stimulate the trophic centres, and an in- 
creased nourishment to the hair bulb is a result. 

Symptoms. The disease may attack any hairy portion 
of the body, but most commonly the scalp, and next most 
frequently the beard. The disease usually makes its ap- 
pearance suddenly, often within twenty-four hours. The 
patient may go to bed with a normal head of hair, and 
wake up in the morning with several bald patches. 

In other cases the baldness comes on less rapidly, it 
taking several days to a week or more for the bald patches 
to form. These patches when formed are about the 
size of a silver dollar, some smaller, others larger, round 
or oval in outline, except where several unite together, 
producing irregular patches. Any portion of the scalp 
may be attacked, but over the parietal bones most fre- 
quently. 

Around the margins of the patches the hair is normal. 
The baldness is generally complete in the affected area, 
the skin being unusually white, soft, smooth, and more or 
less atrophied. Sensation in the skin is often diminished. 
Subjective sensations are not well marked. They are 
sometimes absent altogether, and when present consist of 
a little burning or itching. Usually not more than one 



ALOPECIA AREATA. 47 

patch begins at a time, but they follow each other till there 
is often two or more lesions present. 

Course. The disease is a very slow one, lasting for 
months, but gradually ending in recovery of young sub- 
jects, lanugo first making their appearance in the bald 
area. In older people the prognosis is not so good. 
Months or years may elapse before recovery takes place. 
If no hairs appear in these lesions after five years, the 
baldness will remain permanent. Relapses are common. 

Diagnosis. The clinical symptoms of this disease are 
usually so clear that you will seldom have any difficulty 
in diagnosing a case of alopecia areata. The only diseases 
with which you are at all liable to confound it are syphi- 
litic alopecia and ringworm of the scalp. 

Treatment. The treatment of alopecia areata is unfor- 
tunately not always attended with a good result. As the 
disease is considered by most dermatologists due to ener- 
vation, internal treatment is recommended in the way of 
cod-liver oil and nerve tonics,especially strychnine, arsenic, 
and phosphorus ; but I have seldom seen any good re- 
sulting from the use of these drugs except in cases where 
the general health was run down. Cases of alopecia areata 
accompanied by severe neuralgic pains at the seat of the 
lesions, are often very much benefited by large doses of 
quinine. We must depend almost entirely upon external 
agents to effect a cure, and you will be wasting your time 
in the employment of all remedies which are not stimu- 
lating in character. One of the best agents to use every 
few days when the lesions are not very extensive is a 
lotion composed of equal parts of tincture of iodine, car- 
bolic acid, and chloral, which should be applied with a 
camel's-hair pencil. This will set up a certain amount of 
dermatitis, which must be controlled by the use of some 



48 LECTURES IN DERMATOLOGY. 

oil or mild ointment. Occasionally blistering the scalp 
in the affected area with cantharides is a very useful 
method of treatment. Some dermatologists prefer the 
use of stimulating lotions, and those containing ammonia 
and tincture of cantharides yield the best result. They 
should be used once a day, and strong enough to produce 
some redness and smarting. 



LECTURE IV. 

AS TEA TO SIS, CHLOASMA, CLA VUS, COMEDO, DERMA TITIS 
VENENATA, AND ECTHYMA. 

ASTEATOSIS OR XERODERMA. 

Gentlemen : 

I will first call your attention to-day to a disease which, 
in its milder form, is not uncommon, and called asteatosis 
or xeroderma. 

Patliology. Xeroderma must not be confounded with 
the rarer skin affection ichthyosis, with which it is very 
closely related, the two terms being often used synony- 
mously. The pathological conditions existing in the 
disease xeroderma are found confined to the epidermis, 
and consist of an hypertrophy of the horny layers with 
an excessive proliferation of the cells of the epidermis. If 
the hypertrophy extends to the deeper layers of the skin 
other changes take place, and the disease is then properly 
an ichthyosis. 

Etiology. True ichthyosis is usually a disease born 
with the patient, although it may not become apparent 
until the second or third year. Xeroderma, however, 
although frequently noticed in early childhood, may not 
show itself until later in life. It is supposed by some to 
be hereditary. The direct cause is very obscure, as those 
suffering from the disease are often in the best of health. 
By some dermatologists it is considered a deformity of 
the skin rather than a disease of it. 



50 LECTURES JN DERMATOLOGY. 

Symptoms. Harshness and dryness of the skin with fur- 
furaceous and bran-like desquamation are the most marked 
symptoms. Upon the lower extremities, below the knee, 
the scales are often thin, large, and polygonal or diamond- 
shaped, resembling^ fish-scales. The scales are usually 
whitish and gray in color, and their abundance varies 
greatly in different patients. In those who do not bathe 
frequently or make applications to the skin they often 
accumulate in large quantities, giving the skin a white 
appearance. The disease is usually extensive, covering the 
whole or greater portion of the body, but it is most marked 
on the extensor surface of the extremities and in the 
lumbar and gluteal regions. The disease is always worse 
in winter than in summer, although persons affected with 
the disease sweat but slightly in the affected regions. The 
subjective symptoms are not very severe. There is a 
sense of abnormal dryness in the skin and some itching. 
The disease is a very chronic one, and not very amenable 
to treatment. 

Treatment. A residence in a warm, moist climate is 
always to be recommended. Internal remedies do not seem 
to have much effect. The prolonged use of arsenic, cod- 
liver oil, and alkalies seem to have some beneficial action. 
We have to depend mostly on external applications. 
Alkaline and bran baths should be employed every night, 
and the skin then thoroughly rubbed with turtle oil or 
cod-liver oil. Vapor baths and tincture of green soap 
should be used once a week. A 10 per cent, ointment of 
iodide of potash is recommended by some dermatologists 
as a serviceable remedy in this complaint. 
CHLOASMA. 

A disease which you will all be called upon to treat is 
chloasma. 



CHLOASMA. 51 

Pathology. This hypertrophic skin affection has its seat 
in the pigmentary layer of the skin, and consists simply 
in an increased deposit of normal pigment. The patho- 
logical progress is undoubtedly under the influence of the 
nervous system, but in what way we do not know. After 
the pigment is once deposited it may be slowly absorbed, 
or remain for an indefinite period. 

Etiology. The disease is much more common in women 
than men, and usually results from some functional or 
organic derangement of the internal organs, as the uterus 
or suprarenal capsules. Sudden shock to the nervous 
system and various neurotic disturbances not infrequently 
are the direct cause of chloasma. Pigmentary deposit in 
the skin secondary to other skin lesions, should not be 
confounded with primary chloasma, the affection we are 
now considering. 

Symptoms. The tissues of the skin are not altered in 
structure, the only change being the pigmentary deposit, 
and this is not associated with any subjective symptoms. 
In the majority of cases this discoloration comes on gradu- 
ally, in patches of rounded or irregular shape. When 
first noticed they are usually about the size of a small 
coin and not very distinct, but gradually increase both in 
size and color, and with a well marked line of demarca- 
tion in some cases. The color of these patches varies 
from a yellow to a dark brown, often having a muddy 
appearance. The patches seldom become larger than the 
palm of the hand, although several may run together, 
covering a large surface. These patches are several in 
number and may appear upon any portion of the body, 
but are especially apt to appear upon the forehead, neck, 
face, and hands. This usual form of the disease is associ- 
ated frequently with uterine disorder. When chloasma 



52 LECTURES IN DERMATOLOGY. 

results from some general disease, as malaria, cancer, 
Addison's disease, etc., the pigmentation is more general 
and of a bronze tint. This is more pronounced, however, 
upon those regions having a disposition to normal in- 
crease of pigmentation, as the hands, face, axilla, nipples, 
and genitals. The color of the hair is also sometimes 
changed to a deeper shade. 

Diagnosis. There are three diseases for which you are 
liable to confound chloasma. They are tinea versicolor, 
pigmentary syphilide, and leucoderma. Leucoderma, 
which is an abnormal whiteness of the skin, is often asso- 
ciated with chloasma. 

Treatment. The treatment should consist both in 
internal medication and external applications. The 
internal treatment depends entirely upon the cause of 
the disease, for by removing it the pigmentation will 
frequently entirely disappear. Frequent examples of the 
disappearance of chloasma, the result of pregnancy, of 
uterine disorders and of malaria, after the cause has been 
removed, have been recorded by many observers. It has 
been claimed by some that these pigmentary stains can 
be removed by the internal administration of certain 
drugs, as mercury, arsenic, and the iodide of potash, and 
in certain cases it does seem to hasten their absorp- 
tion. For external application there are four drugs which 
seem to hasten the disappearance of these pigmentary 
stains. They are bi-chloride of mercury, resorcin, acetic 
acid, and sulphur. The following combination is a very 
good one: 

B Resorcini 3 ss 

Hyd. chlor. corr gr. 

Ac. acetic, dil 3 

Aq ad ? 

m 



CLA VUS. 5 3 

and should be applied over the patches two or three times 
a day with a camel's-hair brush. At night an ointment 
composed of one drachm each of ammoniated mercury 
and subnitrate of bismuth to the ounce is favorably spoken 
of by Neumann. Remember, whatever plan of treatment 
you adopt, the result is always slow and often very un- 
satisfactory. For the more rapid removal of the patches 
the following method has been suggested by Hebra : A 
solution of corrosive sublimate, five grains to the ounce of 
alcohol, is applied continuously by means of compresses. 
The compresses are to be kept moist by the addition of 
the fluid from time to time, and are to be retained in 
position for about four hours, when the skin will be blis- 
tered. The epidermis is to be removed, and the surface 
dressed with starch powder. The newly formed epider- 
mis will be devoid of pigmentation, but the discoloration 
is apt to return after a certain period. Another method 
which is not quite as heroic but yields just as good results, 
consists in painting lightly on the pigmented patches 
every two or three days with the following application : 
5 Acid, carbolic, 

Chloral, hyd., 

Tinct. iodi aa 3 ii 

m 

If no benefit results after six or eight applications there 
is no use of continuing with it. 

CLAVUS. 
Synonym — Com. Avery common and painful disease 
of the skin, and one which is too frequently looked upon 
by the physician either as too trivial or else beneath his 
dignity to treat, is clavus, or corn ; consequently the 
chiropodist or " corn doctor " thrives and gets wealthy 



54 LECTURES IN DERMATOLOGY. 

for relieving, but seldom curing his patient. Let me im- 
press upon you the fact that a corn is not such a trivial 
matter. It is one of the most painful of all skin diseases, 
and one of the hardest to cure. Many a patient would 
give more to get rid of his corn than his eczema, yet we 
send one often to a quack for treatment of his greater 
evil, while we attempt to cure him ourselves of the lesser. 
If any of you have ever been the referee in a conflict be- 
tween a sensitive corn and a tight shoe, I am sure no 
words of mine can express too forcibly the importance of 
that position. Try as you will to become interested in 
other matters, nothing can distract your mind from the 
painful interest you feel in that unequal contest. The 
knowledge of a corn on the little foe of a philanthropist 
will cause him much more sorrow than the news that a 
thousand Chinamen have been drowned in the floods 
which invade that country. 

Pathology. The growth consists of a circumscribed 
hypertrophy of the epidermis, usually of horny consis- 
tency, containing an inverted cone-shaped centre or core, 
the apex of which rests upon the corium, often causing 
atrophy of that structure, which results in a cup-shaped 
depression into which it fits. In structure it is composed 
of concentric layers of epidermic cells. The pain is pro- 
duced by this sharp-pointed core, which presses upon the 
nerves in the true skin, these nerves often being inflamed 
or in an excitable condition. 

Etiology. Corns are almost always the result of pres- 
sure, but may come from friction. Tight-fitting shoes 
will produce corns from pressure, while loose-fitting ones 
may produce the same result from friction. 

Symptoms. Corns most frequently appear upon the 
feet and over the joints of the toes where friction and 



CLA vus. 5 5 

pressure are usually the greatest. They first appear as 
callosities upon those portions of the skin which are 
naturally most exposed, or when seated upon sensitive 
moist skin, as that between the toes, the lesions, although 
made up of the same pathological elements, are soft. 
Hence we use the term hard and soft corn to express the 
clinical features which they present. The lesions are 
from a pin-head to a split pea in size, and very painful on 
pressure. Sometimes there are present sharp, shooting, 
intermittent pains in the lesions where no pressure exists. 
This is especially apt to occur after patients have gone 
to bed at night. Not infrequently, if the irritation to a 
corn is continuous, it will set up an inflammation in the 
corium about the core which terminates in suppuration. 
When this occurs on the sole of the foot the destructive 
process sometimes extends in form of a sinus deeply into 
the tissues of the foot, and the disease is then known as 
perforating ulcer. This ulcer and sinus is surrounded 
by hard, callous tissue and very difficult to heal. These 
conditions sometimes simulate very closely the forms of 
ulceration found in the feet, the result of spinal-cord 
disease. 

Treatment. The treatment of corns is always local, 
and may be palliative or curative. In the first place the 
cause must be determined and removed. The palliative 
methods of treatment have the same objects in view in 
removing the core, which will always give immediate re- 
lief but will seldom cure, for the core will grow again in 
a few weeks or months unless all pressure and friction are 
removed from the affected area. To cure the corn, not 
only must the core be removed, but the callous tissue 
about it. To do this we may either resort to the knife, 
or to various applications. 



56 LECTURES IN DERMATOLOGY. 

Surgical treatment. By a cutting operation all the core 
and callus surrounding it may be removed, and the edges 
of the wound brought together with sutures. This may 
be done without pain if a little cocaine be injected about 
the core. There are some objections to thus operating 
on a corn. In the first place, as the lesion is apt to be over 
bony prominences it may be difficult to bring the edges 
of the wound together after the incision, or to keep them 
together, in which case the wound heals slowly by granu- 
lation. In the second place, the scar is apt to remain 
sensitive, owing to the friction and pressure, which it is 
almost impossible to keep from the diseased area. In the 
third place, many patients object to a cutting operation 
of any kind, and you will be forced to resort to other 
means. However, in many cases this simple operation 
is followed by the best results and a complete and perma- 
nent cure. 

Medical treatment. The medical treatment of corns 
would fill a book the size of a dictionary, and I shall not 
attempt to go all over the subject. I shall give you the 
plan of treatment which I consider the best. The treat- 
ment for a hard and soft corn is a little different. For a 
hard corn paint over the centre of the lesion with liquor 
potassi, which will in a few minutes so soften the core 
that it may be removed with very little difficulty, which 
will give the patient relief from pain. Then tell your 
patient every night before retiring to bathe the corn in 
hot water for fifteen minutes, dry thoroughly, using con- 
siderable friction, and then apply on a bit of lint some 
diachylon ointment, containing 5 per cent, of salicylic 
acid, and bind on snugly. In the morning this may be 
removed, and a corn plaster applied to keep the part 
from pressure. This treatment should be continued for a 



COMEDO. 57 

week, after which a strip of mercurial plaster should be 
applied, and worn continually for some time. With this 
treatment, and attention paid to the removal of all further 
cause of the trouble, a complete cure usually results. If 
all pressure is removed from a soft corn, it usually heals 
very rapidly without much treatment. They also heal 
very rapidly if painted over with a 5 per cent, solution of 
aristol in flexible collodion. This application should be 
made every day or two until the corn is healed, which 
usually takes place in a week if all irritation and pressure 
be removed. After a cure is effected, great care must be 
taken to prevent a relapse by separating the toes with a 
little cotton wool, when the lesion grows, as it usually 
does, between the toes. When it occurs on the sole of 
the foot, a corn plaster may be used with advantage, or a 
strip of mercurial plaster, applied continually. 

This is one method of treating both the hard and soft 
variety of corns. The only other method which I would 
recommend to you that may be better in a certain per- 
centage of cases is a continued application every day or 
two of the following solution : 

IJ Ac. salicyl. . . 
Ext. can. ind. . 



Alcoholis . . 
yEtheris . . . 
Collodion flex. 



. gr. xv 

• gr. x 

. ffl xv 

• 3 i 
ad 3 iii 



m 



COMEDO. 



You will remember that in my lecture on acne I re- 
ferred several times to the term comedo or comedones. 
Closely allied to and almost always occurring with acne is 
a disease of the sebaceous glands, resulting in the produc- 
tion of what is termed comedones or black-heads. 



58 LECTURES IN DERMATOLOGY. 

Pathology. The disease has its seat in the sebaceous 
glands, and consist of an accumulation of sebum and 
epithelial cells in the glands and follicles, dilating the 
ducts to such an extent as to produce a point of elevation 
on the skin. These elevations are usually black; and, 
according to Unna, the color is the result of pigment 
deposit in the epithelial cells, but it is probably most 
frequently a mixture of dust or dirt with the sebum. The 
inflammatory process is seldom an active one, but when 
it is, it may result in the production of acne pustules. 

Etiology. The disease is usually due to an inactivity 
of the sebaceous glands, either the result of improper care 
of the skin, or to some functional derangement of the 
digestive or generative organs. The idea held by many, 
that the disease is due to a flesh-worm, is, of course, 
erroneous, although a little microscopic parasite, known 
as the demodex folliculorum, is sometimes found mixed 
with the sebum of the comedo. 

Symptoms. Comedones appear as little black elevations 
in the skin, usually pin-point in size, although frequently 
larger. They are attended with no subjective symptoms, 
unless active inflammation is set up in the gland, when 
acne results. The skin about the comedone is usually 
dirty, muddy, and greasy-looking. The disease occurs 
most frequently in young people under twenty years of 
age, and attacks the face, back, and chest in preference to 
other portions of the body. They may occur singly, 
but usually in numbers, even to such an extent as to be 
disfiguring. 

Course. The lesions come and go from time to time, 
but the disease is very sluggish, and lasts for years. Even 
under treatment they often prove rebellious. 

Treatment. The mechanical treatment consists of 



DERMA TITIS. 59 

squeezing out the contents of all the follicles. Instru- 
ments are made on purpose for this, but a watch-key 
usually answers every purpose. Hot applications and 
friction to the diseased surface with tincture of green 
soap are very serviceable. The lotions recommended 
for acne are also especially beneficial in cases of comedo. 

There is nothing to be done in the way of internal 
treatment, except regulating the diet, and giving atten- 
tion to any functional derangement which may exist and 
be the cause of the disease. 

Tonics may be of some service in cases of the disease 
occurring in the anaemic or debilitated. 

DERMATITIS. 

The next subject I will call your attention to to-day is 
dermatitis. Under this general term dermatitis is in- 
cluded all those simple inflammatory diseases of the skin 
which are mostly caused by external irritation, as heat, 
cold, caustics, poisons, etc., and also by the internal 
administration of certain drugs, all of which result in 
similar conditions as to their pathological anatomy, differ- 
ing only in the intensity of the inflammation. If the 
inflammation is slight a simple erythema results ; if more 
extensive the presence of wheals or vesicles or blebs or 
pustules, even gangrene of the skin, shows the severity 
of the skin affection, — the character of the lesion depend- 
ing entirely upon the grade of the inflammation. The 
usual signs of inflammation — heat, swelling, redness, and 
pain — are also always present. The terms given to the 
various forms of dermatitis are derived from the causes 
which produce them, and are as follows : Dermatitis 
traumatica, Dermatitis venenata, Dermatitis calorica, 
Dermatitis medicamentosa. 



60 LECTURES IN DERMATOLOGY. 

DERMATITIS VENENATA. 

The only variety of dermatitis which I have time to 
describe to you is that form of dermatitis venenata which 
is produced by the poison-ivy, or rhus toxicodendron. 
This inflammation is due to an acid which occurs in the 
plant, called toxicodendric acid. As this acid is volatile it 
is not necessary for the plant to come in direct contact 
with the skin, but proximity to it, or the smoke produced 
by burning it, will in persons susceptible produce a der- 
matitis. All persons, however, are not susceptible to 
the influences of the acid, some not being affected at all 
by handling it. 

Symptoms. The eruption usually makes its appearance 
within twenty-four hours after exposure, and usually upon 
the exposed portion of the body, either the face or hands. 
Next in frequency it occurs about the genitals, being car- 
ried there by the poison on the hands of the individual. 
Sometimes it occurs only on the genitals, the sensitive 
skin there being more susceptible to the poison than the 
hardened epidermis of the hands and face. 

The eruption is either erythematous or vesicular, almost 
always the latter. It may begin as an erythema upon 
which vesicles form, or it may be vesicular from the begin- 
ning. In either case, the vesicles, when formed, are situ- 
ated upon an inflamed and cedematous surface. The 
vesicles are very irregular in shape, varying from a pin- 
head to a split pea in size, showing a tendency to group, 
and often running together, forming blebs. About the 
second or third day the eruption is at its height, and 
swelling, pain, itching, redness, and cedema are marked 
symptoms. At the end of three or four days the vesicles 
rupture, and the fluid dries into yellowish crusts. At 
the end of a week the inflammation gradually subsides. 



DERMATITIS VENENATA. 6 1 

the crust becomes detached, leaving a reddened surface 
beneath. 

Course. The disease lasts about two weeks on an 
average, but some cases have a tendency to terminate in 
a chronic eczema of the affected area, which lasts for 
months. This condition is most often seen in persons 
who have an eczematous tendency, or as the result of in- 
judicious treatment. 

Diagnosis. The only disease for which you are at all 
liable to mistake ivy poisoning is vesicular eczema, which 
is, by the way, a very common mistake to make, and 
shoulcf always be guarded against. 

Treatment. Internal treatment by the administration 
of belladonna is well thought of by many, and does seem 
to lessen the symptoms and the length of the attack in 
some cases. Homoeopathic physicians use internally the 
same remedy which caused the disease, namely, rhus, and 
claim great results by this method of treatment. .. 

Usually external treatment is all that is required. If 
seen in the very beginning of an attack, before the vesicles 
are formed, dusting powders — as buckwheat flour and 
starch — seem to relieve the symptoms and check the 
severity of the disease. In the later stages, when the 
acute symptoms are well marked, soothing and astringent 
lotions give the best result. A lead and opium wash, as — 

B Liq. plumb, subacet 3 ii 

Tinct. opii 3 i 

Aq ad f ii 

m 

kept continually applied, acts very nicely ; but a little care 
must be exercised, especially in children, when the area is 
large, as poisoning may result from absorption of the 



62 LECTURES IN DERMATOLOGY. 

drug. A much safer lotion to use, although not quite as 
efficacious, is the following, which must be kept continu- 
ally applied : 

I£ Calaminae, 

Zinc, ox aa 3 ss 

Glycerini 3 ii 

Liq. calcis ad ? ii 

m 

An application of grendelia robusta, one drachm of the 
fluid extract to four ounces of water, acts very nicely. 
After the inflammation has subsided, and the vesicles 
have ruptured, a soothing and astringent ointment should 
be used, such as diachylon. If the disease shows a ten- 
dency to run into chronic eczema the more stimulating 
ointments containing tar should be used, a drachm of the 
oil of cade to the ounce of diachylon ointment being a 
favorite remedy. 

ECTHYMA. 

If you practise much among the poor, especially in large 
cities, or among emigrants, you will frequently see a dis- 
ease called ecthyma. 

Pathology. This disease is a markedly inflammatory 
one, and affects the papillary layers of the skin. The 
exudation is largely purulent, and, collecting in the centre 
of the inflammatory area, forms a pustule, while the sur- 
rounding skin becomes infiltrated, congested, and swollen. 
The deeper layers of the skin are seldom affected, so that 
scarred or permanent lesions seldom result. Pigmentation 
at the seat of the lesion may, however, remain for some 
time. 

Etiology. The disease always occurs in those who are 



ECTHYMA. 63 

physically in a poor condition. It is often called a 
''poor-" or "tenement-house" eruption. The want of 
proper hygienic conditions is therefore the most common 
cause for the disease. It occurs in both children and 
adults, and is not contagious. Continued irritation of the 
skin may produce ecthyma in those disposed to it, and it is 
of frequent occurrence in persons suffering from scabies. 

Symptoms. The eruption begins as a small pustule 
situated on an acutely inflamed surface, which is reddened 
and infiltrated. These pustules increase in size, and also 
the inflammatory area around them, until they reach the 
size of a thumb-nail. At first they are yellowish, but 
soon acquire a red tinge owing to blood becoming mixed 
with the pus. The lesions are fiat and rounded, with 
their walls not fully distended, but exhibiting a sharp 
outline. After existing for a few days the lesions become 
more and more flaccid, the pustules forming into brownish 
or black crusts, which are easily detached, leaving an 
excoriated, ulcerating surface covered with a bloody crust.. 
If these crusts are allowed to remain on, the surface be- 
neath heals slowly, so that they do not fall off spontane- 
ously for two or three weeks, leaving a pigmented surface 
sometimes slightly scarred. New pustules appear from 
time to time. They mostly occur about the lower ex- 
tremities, but also appear on the back and shoulders. 
They are accompanied by considerable pain and much 
tenderness. Itching is present at times. The lesions are 
usually discrete. 

Course. The disease lasts indefinitely, so long as the 
cause is kept up by the reappearance of new lesions, 
which may appear singly or in groups. 

Diagnosis. The lesions of ecthyma may be mistaken 
for those of impetigo, large, fiat, pustular syphilide, pus- 



'64 LECTURES IN DERMATOLOGY. 

tular eczema, and furunculosis ; especially are they liable 
to be mistaken for the pustular syphilide. 

Treatment. Dietary treatment and tonics in this skin 
disease are more useful than external applications. Good, 
nutritious food, such as beef, eggs, milk, ale, porter, etc., 
should be allowed, and the patient placed in the best 
hygienic surroundings. Tonics of iron, quinine, arsenic, 
and strychnine should be given. Soothing ointments 
should be applied to the lesions. If crusts have already 
formed they should first be removed by soaking in oil or 
by poulticing. The whole affected area should be washed 
once or twice a day with a I : iooo bichloride of mercury 
solution, and the following ointment 

5 Hyd. ammon 3 ss 

Hyd. chlor. mit 3 iss 

Adipis ad 3 i 

m 

applied under a snug bandage. Aristol powder over the 
lesions, after the crusts are removed, often hastens cica- 
trization, or it may be used in a io-per-cent. ointment 
with vaseline. 



LECTURE V. 

ECZEMA. 

Gentlemen : 

We now come to consider the most common of skin 
diseases in the point of frequency, for from an analysis of 
many thousand cases of skin diseases eczema was found 
to equal about one third of the whole number. This 
proportion is probably somewhat too high, for the ten- 
dency of many physicians to call all skin diseases eczema, 
as a loop-hole for their ignorance, is only equalled in 
frequency by their number of cases of malaria. There is 
some excuse for this, however, for, besides the frequency 
with which eczema occurs, it takes on so many different 
clinical forms that it may simulate almost every variety 
of skin disease. However, it is very unscientific to call a 
skin disease eczema simply because you do not know 
what it is. 

Pathology. Eczema is an exudative inflammation of 
the skin, which undergoes many rapid changes during its 
development. As we have exudative inflammation with 
the production of either serum or pus depending un- 
doubtedly upon the violence of the inflammatory process, 
so we find in like inflammations of the skin the same 
products of inflammation depending upon the variety of 
the eczema. 

The varieties of eczema possess, however, some features 
in common. There is, in the first place, a hyperemia or 
5 65 



66 LECTURES IN DERMATOLOGY. 

congestion of the skin, either general as in erythematous 
eczema, or in points as in the papular variety. In all 
cases, however, it is most marked about the follicles. 
The next pathological process is an exudation from the 
blood-vessels, great or small, fluid or plastic, serous or 
purulent, depending upon the variety of the disease. The 
exudation, consisting of serum and cells, mostly leucocytes, 
takes place in the deeper layers of the rete mucosum and 
the upper layers of the corium. 

If the process ends here and is general there will be an 
erythematous eczema with thickening of the skin, but 
if localized to papillae, a papular eczema is the result. 
When the fluid becomes more abundant it raises the epi- 
dermis in the form of vesicles, producing vesicular eczema. 
If the exudation is purulent rather than serous, pustules 
form producing pustular eczema. In some cases where 
exudation is general rather than localized, the skin be- 
comes bereft of its normal epidermis, the fluid exuding 
directly from the surface without any formation of vesi- 
cles. This variety is termed madidans, or weeping eczema. 
These pathological changes all take place in acute eczema, 
but the alteration found in the skin in chronic eczema is 
of another character. The skin becomes permanently 
hardened and thickened from serous exudation and cell 
infiltration, usually of the connective-tissue variety, which 
extends through the entire corium. The papillae become 
so enlarged as to be seen with the naked eye, and pig- 
mentation takes place in the deeper layers of the rete. 
The blood-vessels become distended, and a serous exuda- 
tion results which infiltrates the cutaneous tissues, espe- 
cially the epidermis, drying on the surface producing scales 
and crusts. 

The skin becomes weakened owing to the infiltration 



ECZEMA. 67 

of products of inflammation into the corium, and, losing 
its elasticity, becomes dense and hard, especially liable to 
crack and become fissured, — lesions which are usually seen 
in chronic eczema. There is seldom any production of 
scar tissue in the skin, the result of eczematous inflam- 
mation. 

Etiology. Eczema is rather more common in males 
than in females. In certain cases it seems to be heredi- 
tary, or, more properly speaking, some persons seem to 
inherit a predisposition to the disease, as we find it occur- 
ring from one generation to another. Persons with light 
hair and florid complexions are more subject to the dis- 
ease than those with dark hair and skin. Causes which 
produce eczema in one person might have no effect at all 
upon another, showing that some persons are much more 
susceptible to the disease than others, and even at one 
time more than another certain causes excite an appear- 
ance of the eruption. 

Constitutional causes. Chief among the constitutional 
causes of eczema are functional derangement of the diges- 
tive organs, especially associated with a large amount of 
urates, or uric acid in the urine. Rheumatism and gout 
are frequently the cause of eczema. Impaired conditions 
of the blood, such as are present in anaemic and strumous 
persons, is a frequent cause of the disease, as is dentition 
in children. What is sometimes described as nervous 
eczema is a form of the disease occurring in persons suf- 
fering from nervous debility. 

Local causes. Eczematous eruptions, the result of local 
irritants, are very common, but some authors prefer to call 
all such eruptions, although eczematous in character, der- 
matitis. Familiar examples of such causes are heat, cold, 
poison vines, as rhus ; certain drugs and chemicals, as 



68 LECTURES IN DERMATOLOGY. 

mercury, sulphur, zinc, etc. Continued applications of 
water to the skin will frequently result in eczema ; sudden 
changes of the weather will produce an attack, and the 
disease is more common in winter than summer. 

Pediculi of the scalp and pubis will frequently produce 
eczema, as will scratching of the skin from any cause. 

Please remember that simple eczema is not at all conta- 
gious, although the discharge may become at times so 
acrid an irritant as to set up inflammation on a sensitive 
skin with which it comes in contact, but does so simply 
by its irritating properties rather than by any contagious 
elements present. 

Symptoms. Eczema presents itself in so many different 
forms that it is very difficult to describe intelligently the 
disease as a whole, although they all have some symptoms 
in common. The symptoms which characterize an eczema- 
tous inflammation of the skin are heat, itching, thickening, 
and exudation, and remember you will seldom be called 
upon to treat an eczema that has not at one time or another 
presented these symptoms. The disease begins frequently 
as an erythema ; at other times in the form of papules, 
then again either in the form of vesicles or pustules. The 
characters of the lesions may remain as they begin, but 
more frequently they change into other forms, for there 
is no affection of the skin in which the lesions, both pri- 
mary and secondary, undergo so many and varied altera- 
tions, and so suddenly, as they do in eczema. 

This disease may begin as an erythema, and in a day or 
two the lesions become an excoriated patch terminating 
in thickened, dry, desquamating surfaces ; so the disease, 
beginning as papules, may soon become vesicles, and then 
pustules, thus changing in character from day to day. It 
will be well for you to remember this, otherwise your 



ECZEMA. 69 

various varieties of eczema may seem to run a very erratic 
course. The varieties of eczema, which I will now briefly 
describe to you, are named according to the lesions which 
the disease assumes at its commencement. 

ERYTHEMATOUS ECZEMA. 

This form of eczema usually appears about the face or 
neck, or upon the genitalia. It usually begins as an ery- 
thematous patch about the size of a half dollar, and 
spreading gradually into the surrounding skin. The 
patch has an ill-defined border fading imperceptibly into 
the surrounding skin. The affected skin is slightly thick- 
ened, pale red, or bright red in color, sometimes viola- 
ceous, having a dry surface covered with fine scales. 
After the disease has lasted for some time the surface 
becomes dotted with bright red points, the deeply con- 
gested papillae. Itching is usually a very marked symp- 
tom. This form of the disease is more apt to occur in 
old people, especially men. 

Course. The disease may last but a week or two and 
then disappear, but is very apt to return and last longer 
each time it reappears, until it becomes chronic. Even 
when chronic it is apt to be better some days than others, 
the disease being easily influenced by changes in the 
weather or over-indulgence in food or drink. It may 
always remain erythematous in character, but frequently 
changes into a moist, weeping eczema with crusts, espe- 
cially when two affected surfaces come in contact. More 
frequently it terminates in desquamation, becoming 
eczema squamosum. 

VESICULAR ECZEMA. 

Vesicular eczema usually begins with an itching and 
burning in the part to be affected. This is accompanied 



70 LECTURES IN DERMATOLOGY. 

by redness of the skin, which increases until after a few- 
hours minute pin-head-sized vesicles make their appear- 
ance. These are usually at first discrete, but run together, 
becoming confluent. They increase in size and become 
distended with a yellowish serum, rupture spontaneously 
or by scratching, the fluid spreading over the surface and 
drying in yellowish crusts. This process takes but a day 
or two, and may be succeeded by new crops of vesicles, 
but usually the epidermis being denuded new vesicles do 
not form, but the exudation of serum continues. The 
face and hands are especially apt to suffer from this 
variety of eczema, but any part of the body may be 
affected. The extent of surface attacked varies very 
greatly. This variety of eczema may occur alone, but is 
more apt to be associated with the formation of papules 
and pustules. The lesions fade gradually into the sur- 
rounding skin, but the line of demarcation is better 
marked than in the erythematous form. 

Course. The disease may last but a few days, drying 
up and getting well, but the skin may become more and 
more thickened, red, and weeping, the disease passing 
into a chronic condition known as eczema rubrum. 

ECZEMA PUSTULOSUM. 

Pustular eczema, or impetiginous eczema, as it is fre- 
quently called, most often begins as a vesicular variety, 
but it may be pustular from the start. Again, both 
lesions may be present at the same time. The early 
symptoms are the same as those described under vesicular 
eczema, but the pustules when formed are usually larger 
than the vesicles and firmer in consistence. When they 
burst the crusts forming have a greenish-yellow color, 
which are thick and bulky. The pustules have a tendency 



ECZEMA. yi 

to run together, and may thus cover a considerable extent 
of surface. They are more apt to occur on the face, 
scalp, and hands. A number of patches may form at 
about the same time, and uniting almost cover the face 
and scalp with disfiguring crusts, which dry up and fall off 
in a few days, leaving a reddened skin which very gradu- 
ally resumes its normal appearance. Burning and itching 
are present, but are not usually so severe as in vesicular 
eczema. The disease is most apt to occur in children, 
especially those of a strumous diathesis. 

Course. The disease usually runs an acute course, ex- 
cept when present on the scalp, when it lasts for a long 
time. The disease is especially apt to reappear from time 
to time. 

ECZEMA PAPULOSUM. 

Papular eczema or lichen simplex usually makes its 
appearance suddenly in the form of numerous, discrete, 
pointed papules of pin-head size, either in groups or dis- 
seminated. They usually remain as papules, but some of 
them may become vesico-papules or vesicles, both lesions 
being present at the same time. The disease is generally 
extensive, showing a preference for the flexor surfaces of 
the extremity. The itching is most intense, the patient 
scratching the summits off the papules, causing them to 
bleed and thus forming blood crusts. From the result of 
scratching a moist eczema may be set up in places. 

Course. This form of eczema almost always runs a 
chronic course, but is less apt than other varieties to 
undergo any change. It begins as papules and ends as 
such. Each individual lesion lasts for many days, and 
when it disappears it is apt to be replaced by others. 
Relapses are very common. 



72 LECTURES IN DERMATOLOGY. 

CHRONIC ECZEMA. 

Any one of the acute forms of eczema just described 
may terminate in chronic eczema. The division between 
acute and chronic eczema relates not to the length of 
time that the disease has lasted, but to the pathological 
changes which take place in the skin when the disease 
becomes chronic, and to the symptoms which accom- 
pany these changes. 

ECZEMA RUBRUM. 

In one form of chronic eczema, called eczema rubrum, 
the disease is characterized by thickened, reddish, weep- 
ing skin with a denuded surface. This serous exudation, 
often tinged with blood, dries into greenish or brownish 
crusts, which adhere closely to the surface, and when re- 
moved leave a deeply inflamed surface beneath, which 
exudes freely and bleeds easily. This form of eczema 
occurs often in old people, and especially about the legs. 
It is often associated with ulcerations, which, from vari- 
cose conditions of the veins, are frequently called varicose 
ulcers. 

SQUAMOUS ECZEMA. 

The other form of chronic eczema to which I will call 
your attention is the squamous variety, and is most fre- 
quently the result of the erythematous form of eczema. 
It is characterized by the presence of smaller or larger 
dry scaly, reddened patches of skin, which are much 
thickened. The scales are usually easily removed, and 
leave a dry surface beneath. Itching is a marked 
symptom. 

Fissures and cracks are of frequent occurrence in 
chronic eczema, and are usually apt to form in regions 



ECZEMA. 71. 

subject to constant motion, as about the hands and 
joints. Occasionally a patch of chronic eczema will take 
on a verrucous form, the warty appearance being due to 
a hypertrophic condition of the papillae. This condition 
is most frequently met with about the hands and feet. 

Diagnosis. I told you in the beginning of this lecture, 
eczema occurs in so many clinical forms that it may 
simulate almost every variety of skin disease. You can 
understand, therefore, how difficult it is in many cases to 
make a differential diagnosis. Erythematous eczema is 
most liable to be mistaken for erysipelas, erythema, 
erythematous lupus, and erythematous syphilide ; papular 
eczema for pediculus corporis, prurigo, lichen planus, 
papular syphilide, papular urticaria, scabies, and lichen 
trophicus or prickly heat ; vesicular eczema for herpes, 
sudamen, scabies, and dermatitis venenata or ivy poison- 
ing ; pustular eczema for impetigo, impetigo contagiosa, 
sycosis, tinea sycosis, pustular syphilide, tinea favosa, 
pediculosis capitis, scabies, acne, and rosacea ; squamous 
eczema for psoriasis, seborrhcea, squamous syphilide, 
tinea trychophytina, and pityriasis ; while eczema rubrum 
is often mistaken for cellulitis and dermatitis. There are 
a great many other diseases which are often mistaken for 
eczema than those which I have just mentioned, but they 
are the ones which you must especially consider in making 
your diagnosis. 

Treatment. The treatment of eczema should be both 
constitutional and local. The diet should be especially 
regulated, for indigestion is frequently an exciting cause. 
The patient should be especially careful not to eat starchy 
or saccharine food, and avoid all sweet wines and malt 
liquors. If the case is a very acute one, a diet of bread 
and milk for a few days may aid materially in effecting a 



74 LECTURES IN DERMATOLOGY. 

cure. If the disease occurs in the plethoric, a very low 
diet should be ordered and insisted upon until the disease 
is quite cured. The bowels should be kept thoroughly- 
open by drinking large quantities of hot water before 
breakfast, with a required amount of Hunyadi water. 
Alkalies should be taken before meals, and the one which 
seems to act uniformly the best is the acetate of potash 
in 1 5-to-20-grain doses. If there is much thickening of 
the skin, or much desquamation, a few drops of Fowler's 
solution may be added with benefit to the potash solu- 
tion. If the case is uncomplicated, this will be about all 
the constitutional treatment required. Eczema occurring 
in the strumous and cachectic, or in children, cod-liver oil 
is one of the best remedies you can use. In the anaemic 
and debilitated iron tonics are required, and perhaps 
stimulants in the way of sour wine or whiskey. Iron, 
when given, should be in some very digestible form, as 
■Startin's mixture — 



Ferri sulph 


. . . gr. ii 


Magnesii sulph 


. . . gr. xv 


Acid, sulph. dil 


. . . TTl iv 


Tinct. gent. comp. . . . 


. . . m x 


Aq 


. . ad 3i 



m 

taken after meals. Stimulants are usually beneficial in 
moderate quantities when the disease occurs in the old 
•and enfeebled, but they should be strictly prohibited in 
the young and strong, for in such cases the disease is 
almost invariably made worse by their use. 

Local treatment. The external applications will de- 
pend very largely upon the kind of eczema you are called 
upon to treat. Remember, as a rule, water should not be 



ECZEMA. 75 

applied to acute eczema, in whatever variety it may 
exist, for water, in the majority of cases, irritates the 
skin. The diseased surface must be kept clean, however. 
In the treatment of erytJiematous eczema powders, 
lotions, or ointments may be applied. Powders contain- 
ing oxide of zinc, talc, and camphor in the following 
proportions — 

1$ Zinc, ox., 

Talci aa | ss 

Camphorae 3 ss 

ni 

are both cooling and antipruritic, and may be dusted over 
the eczematous surface frequently and with great benefit. 
If the diseased area is not very extensive, lotions of cala- 
mine, such as I recommended in the treatment of ivy 
poisoning, or lactate of lead, one drachm of lead water to 
an ounce of milk, may be applied frequently with good 
result, and allowed to dry on the affected surface. Lotions 
cannot be used, as a rule, longer than a few days at a 
time without producing irritation, when we must resort 
to ointments. The ointments should be soothing and 
astringent, but not too drying. The oxide of zinc oint- 
ment is a very good one for acute erythematous eczema, 
and may be used alone, or a half drachm of camphor or 
five grains of carbolic acid may be added to the ounce, 
to relieve the itching. 

Occasionally this variety of eczema becomes universal, 
covering almost the entire body. In this case it is neces- 
sary to keep your patient in bed, give an alkaline bran 
bath for fifteen minutes once a day, after which rub the 
skin thoroughly with the following ointment : 



76 LECTURES IN DERMATOLOGY. 

Ac. carbolic 3 ss 

Glycerit. amyli § iv 

m 

In the treatment of vesicular eczema powders are of 
very little service. Drying and astringent lotions, such 
as were recommended in erythematous form, may be 
used for a few days with a good result, a 5 per cent, ich- 
thyol lotion being especially serviceable when the surface 
becomes denuded, but our chief dependence is upon oint- 
ments. Lassar's paste, which is compounded as follows, 

Acid, salicylic gr. xv. 

Amyli. 

Zinc, ox aa 3 ii 

Petrolat % i 

m 

is perhaps the best ointment I can recommend to you, 
but freshly prepared diachylon ointment is usually as 
good, and acts better in some cases, being more protec- 
tive. These ointments should be applied twice a day, and 
if there are any crusts on the affected surface they should 
first be removed by salicylated or carbolized oil. If the 
ointment is applied to a hairy surface the hair should be 
cut as closely as possible before the application is made. 
When the ointment is reapplied the affected area should 
not be washed, but the excess of oil ointment wiped off 
with a little cotton or lint. 

Should the eczema be pustular, we have to depend 
almost entirely upon the use of ointments, and as we have 
present the micro-organism which produces pus, antisep- 
tics are called for. The antiseptics which can be depended 



ECZEMA. yj 

upon and may be added to the ointments employed, or 
used as a lotion before applying the ointment, are salicylic 
acid 3 to 5 per cent., boric acid 2 to 4 per cent., carbolic 
acid 1 to 2 per cent., and ichthyol 4 to 5 per cent. It has 
recently been found very serviceable to thoroughly cleanse 
the surface of the diseased area with a strong solution of 
peroxide of hydrogen before applying the ointment. This 
is recommended in both the vesicular and pustular forms 
of eczema. Tar ointments are especially serviceable in 
this form of eczema affecting the scalp, the following being 
a very good one, especially in children : 

B 

Ol. cadini 31 

Ung. zinc, ox f i 

m 

In the treatment of the papular form of eczema you will 
have your patience seriously tried if you are fortunate 
enough to keep your patients, for it is often exceedingly 
unsatisfactory. You must depend very largely upon the 
constitutional treatment. Mild applications of any kind 
seem to have but little effect, and stimulating lotions 
seem to act better than ointments. Lotions containing 
carbolic acid 2 per cent, or liquid tar 5 to 10 per cent., are 
those which seem to give the best result. A very good 
lotion to use in the papular-pustular form of the disease is 
the following applied two or three times a day : 

Gum. tragacanth gr v 

Camphor grx 

Sulphur sub 3 ii 

Aq. calcis ad § ii 

m 



78 LECTURES IN DERMATOLOGY. 

Ointments containing tar (liquor picis alkalines) or sulphur, 
are the only ones you can put much dependence upon, 
their strength depending entirely upon the acuteness of 
the disease. 

The local treatment of chronic eczema is directed tow- 
ard relieving the itching and removing the thickening 
of the skin, for if these conditions exist we cannot cure the 
disease. We have, as you remember, simple thickening 
of the skin with the production of scales (squamous 
eczema), or the formation of crusts on a denuded and in- 
flamed surface (eczema rubrum), and in each the treat- 
ment is different. 

Eczema squamosum. In this variety of cases I should 
advise you once in four or five days to rub the affected 
area with tincture of green soap and hot water, thus re- 
moving all the scales, and then gently going over the 
surface with a solution of equal parts of carbolic acid, 
chloral, and tincture of iodine. Between these applica- 
tions, if an acute inflammatory process is set up by them, 
Lassar's paste or diachylon ointment may be kept ap- 
plied ; but if the reaction is not so marked the following 
ointment, 

5 Ung. picis, 

Ung. ac. carb aa 3 ii. 

Ung. diachylon ad § i. 

m 

may be used. If the disease is not very chronic, or the 
skin not greatly thickened, this ointment, containing a 
greater amount of tar, may cure it without any appli- 
cations of the iodide solution. 

Eczema rubrum. In the other form of chronic eczema 
rest in bed may be necessary to effect a cure. The 



ECZEMA. jcy 

crusts must be carefully removed by soaking them in 
warm oil, or by poulticing. This leaves an actively in- 
flamed, raw, denuded surface, with a great deal of thick- 
ening of the skin. To this should be applied once a day 
an oxide of zinc or diachylon ointment, containing from 
2 to 5 per cent, of ichthyol, and the part snugly ban- 
daged. Rubber bandages are recommended by many 
dermatologists, but muslin will usually answer if you can- 
not get the rubber. These chronic cases are rebellious, 
and do not often respond to treatment. Sometimes 
counter-irritation to this actively inflamed surface by the 
tincture of green soap once every few days seems to be 
attended with good results. A soothing ointment should 
be applied immediately after the soap is used. I have 
not time to dwell longer on the treatment of this very in- 
teresting disease. Every case must be treated on its own 
merit to a certain extent, but I have outlined a treatment 
of eczema to you which I trust will be of some service in 
guiding you in the right direction. 



LECTURE VI. 

EPITHELIOMA, ERYSIPELAS, ERYTHEMA, ERYTHEMA 
MULTIFORME, AND ERYTHEMA NODOSUM. 

EPITHELIOMA. 

Gentlemen : 

There are three varieties of epithelioma or skin cancer 
to which I wish to call your attention. First, the super- 
ficial ; second, the deep-seated ; and third, the papillary. 

Superficial epithelioma may make its appearance in the 
form of minute papules on the surface of the skin, or it 
may start from a sebaceous gland or wart, but more 
frequently it begins as superficial, flat, skin infiltration. 
After once starting it may remain quiescent for a num- 
ber of years, but sooner or later the tumor shows a dispo- 
sition to fissure or excoriate, and becomes covered with a 
yellowish crust, under which is a scanty, clear, or bloody 
secretion. These crusts are usually picked off or rubbed 
off a few times, and form again. After a while the in- 
flammatory deposits in the skin increase in size, and 
breaking down ulceration begins. This ulceration is very 
superficial at first, but gradually increases in size as the 
cancerous deposit becomes greater. The edges of these 
ulcerations are usually somewhat elevated, indurated, and 
have a rolled border, but not usually reddened. The 
base of the ulcer is red in color, and secretes a scanty, 
viscid, yellowish fluid. The surface is hard, uneven, and 
80 



EPITHELIOMA. 8 1 

bleeds easily. The pain in this form of cancer is not so 
very great, as the deep-seated structures are not usually 
involved unless it passes into the second or deep-seated 
variety, as it sometimes does. The ulceration is often 
extensive as to the surface covered, but seldom very deep 
except in that form generally known as rodent ulcer, 
which appears upon the upper portion of the face, and 
implicates every tissue in the neighborhood, including 
muscles and bones. The general health remains good, 
and the lymphatic glands are not involved in this form 
of cancer. 

The deep-seated variety begins as a roundish, conical 
tubercle, having its seat in the skin and subcutaneous 
tissue. It may have its starting-place in a wart, but is 
always deep-seated. It is reddish in color, firm to the 
touch, and shows signs of extensive infiltration in the 
surrounding tissues. The growth is always elevated. 
After a few months of growth, which is very slow, this 
little tumor breaks down, usually upon the surface, in the 
form of ulceration, but occasionally in the centre, forming 
a little abscess. In either case the tissue disintegrates, 
and deep ulceration takes place. The edges of the ulcer 
are raised, inverted, hard, and infiltrated. The base of 
the ulcer is uneven, ragged, brownish in color, bleeding 
readily, and secreting a yellowish, viscid fluid. Around 
the ulcer the tissues are hard, infiltrated, and red. The 
destructive process progresses rapidly, and large and deep 
ulceration results, accompanied by severe, lancinating 
pains. The lymphatic glands become involved early in the 
disease, breaking down and suppurating. The general 
health of the patient suffers. They become anaemic and die 
from general exhaustion, or from some concurrent disease. 
This form of epithelioma progresses rapidly, terminating 

6 



82 LECTURES IN DERMATOLOGY. 

in the death of the patient in two or three years, some- 
times sooner. 

The papillary variety of epithelioma usually begins as 
wart-like growths, or as raised, spongy, papillary forma- 
tions the size of a coin or larger. In either case the 
tumors become covered with papillary growths, which are 
at first dry and scaly, but afterwards secrete a viscid fluid 
consisting of sebaceous matter, epithelia, and blood, which 
forms in crusts on the surface. After a time disintegra- 
tion takes place on the surface with ulceration. Exuber- 
ant, fleshy, and uneven granulations spring up, which 
bleed easily. The disease becomes more and more ex- 
tensive and the ulceration greater, involving the deep 
tissue as in the deep-seated variety, although the course 
of the disease is not so rapid. 

Seat of epithelioma. Epithelioma occurs most com- 
monly on the face, the lower lip being a very common 
seat. The mucous membrane of the mouth is also a 
common place for this form of cancer, which may be 
either the superficial or the deep-seated variety. On the 
face the superficial variety is much the more common. 
The papillary variety is apt to occur on the backs of the 
hands and on the glans penis. The superficial variety 
often occurs on the scrotum, and is called " chimney- 
sweep's " cancer. 

Etiology. Local irritation is undoubtedly an exciting 
cause for epithelial cancer. This form of cancer can 
hardly be said to be hereditary. It is much more com- 
mon in men than women. It not infrequently has its 
starting-point in a mole or wart, especially in those sub- 
ject to irritation. The disease seldom occurs before 
thirty years of age, usually after forty. 

Diagnosis. It is seldom difficult to make a diagnosis 



EPITHELIOMA. 83 

of epithelioma, as there are but few diseases of the skin 
for which it is liable to be mistaken. Epithelioma is per- 
haps most often mistaken for a syphilitic lesion, either a 
chancre, or a late tubercular, or gummous syphilide. It 
must also be diagnosed from simple warts, seborrncea, 
and lupus. 

Treatment. Internal treatment does not seem to be of 
much service, except so far as it may improve the general 
health. Local treatment consists in the removal of the 
growth. This may be done by excision, by the cautery 
or by the curette, by caustics or by scarification. The 
superficial variety may be best treated by the dermal 
curette. This should be used thoroughly, until all the 
diseased tissue is removed. The raw surface should then 
be covered for two or three days with pyrogallic acid, 
which seems to have a selective action in destroying dis- 
eased tissue. After this, the ulcer may be treated with 
soothing applications until it is healed. 

The disease can be thoroughly destroyed by caustic 
applications, which will act sufficiently upon diseased tis- 
sue without destroying the healthy skin, so that there is 
almost an excuse for the fallacy that they exercise a posi- 
tive power of selection. The resulting cicatrix, when the 
deep subcutaneous tissues are not involved, is a smooth, 
white, and in every way healthy one, and far less con- 
spicuous than those remaining after operation. The only 
cases in which an operation should be preferred to a 
caustic are those affecting the mucous surface of the lip, 
the eyelids, and all others which might have involved a 
large surface, in which dangerous poisoning might result 
from absorption. 

The choice of a proper escharotic is of considerable 
importance. If the disease be a small warty growth, the 



84 LECTURES IN DERMATOLOGY. 

potash and cocaine paste of Mr. Jennings is a good one, 
the composition of which is as follows : 

B Hydrochlorate of cocaine .... 3 i 

Caustic potash 3 vi 

Vaseline 3 iii 

m 

Acetic acid must be at hand to limit its action as soon 
as desired. Marsden's paste, or other strong preparations 
containing arsenic or chloride of zinc, maybe applied, but 
their action is slow, having to be kept applied for several 
hours, and intensely painful. Their action is, however, 
extensive, so that they may be used in the deep-seated 
variety or in the papillary form. The surfaces must be 
denuded, if not already ulcerated, by caustic potash, to 
render the action prompt and effective in the shortest 
possible time. Perhaps the safest and best paste is Bou- 
gard's, which is made as follows : 

^ Wheat flour 60 grammes. 

Starch 60 " 

Arsenic 1 " 

Cinnabar 5 " 

Sal ammoniac .... 5 " 

Corrosive sublimate . . 0.50 centigramme. 
Solution of chloride of 

zinc at 52 F 245 grammes. 

m 

The first six substances are separately ground and 
reduced to fine powder. They are then mixed in a 
mortar of glass or china, and the solution of chloride of 
zinc is slowly poured in, while the contents are kept 
rapidly moved with the pestle so that no lump shall be 



ERYSIPELAS. 85 

formed. A thick layer of this is spread on cotton and 
left in position twenty-four hours, and after they are 
removed poultices should be applied to hasten the absorp- 
tion of the sloughs produced, and then mild dressings 
applied. 

In the deep-seated variety, however, the best result is ob- 
tained by the excision of the tumor, and plastic operation. 
Whatever treatment is applied skin cancer is very prone 
to return within a few years, in or about the scar or the 
seat of the former growth. 

ERYSIPELAS. 

Synonym, St. Anthony s fire. 

Pathology. Erysipelas is regarded by some as a conta- 
gious, constitutional disease (as scarlet fever), with local 
skin lesions, by others as an infectious skin disease with 
constitutional symptoms. 

Dermatologists usually describe it as a skin disease. 
Certain it is that it differs from the general infectious 
diseases by the fact that one attack does not prevent 
another, but rather predisposes toward a second. Besides, 
we know that the general contagious diseases may be ac- 
quired by taking into the system, by means of the respi- 
ratory or alimentary ducts, the poisonous agents which 
produce the affection, while it is very doubtful if erysipe- 
las is ever produced except by direct inoculation through 
the medium of a wound or abrasion in the skin. The 
pathological conditions found in erysipelas may affect the 
skin alone, or the skin and areolar tissue beneath. When 
the deeper structures become involved abscesses are apt 
to form, and the disease is then known as phlegmonous 
erysipelas, to distinguish it from simple erysipelas of the 
skin. Under the microscope the skin and subcutaneous 



86 LECTURES IN DERMATOLOGY. 

tissues are found to be infiltrated with serum and cells, 
which in some places lift up the epidermis in the form of 
blebs or bullae. The blood- and lymph-vessels are en- 
gorged, as are also the cutaneous follicles. The walls of 
the lymph channels and lymphatic glands in the neigh- 
borhood of the affected skin are infiltrated with products 
of inflammation, the glands not infrequently breaking 
down. 

Etiology. The disease is undoubtedly due to a micro- 
organism called the erysipelas coccus, which, coming in 
contact with some abrasion of the skin or mucous mem- 
brane, causes the disease. This coccus multiplies rapidly, 
and is found with the microscope in great numbers, 
especially in the affected skin about the edges of the 
lesions. 

Symptoms. The disease is almost always ushered in 
with a rigor or chilly feelings, soon followed by a high 
rise of temperature and frequently vomiting. The pulse 
is accelerated, tongue coated, lips parched, headache, 
frequently delirium, — in fact all those symptoms usually 
present in cases of severe disturbance of the vital organs, 
such as are found in acute constitutional diseases. Within 
a few hours the skin lesion makes its appearance, almost 
always about some wound, which may have been so slight 
as to escape notice. A crack in the lip, an abrasion of 
the mucous membrane of the nose, may be the starting- 
point. The eruption begins as a red spot or blush with a 
raised, sharply defined, irregular border, which gradually 
becomes larger by extension of its boundaries. The out- 
line always remains very well defined, the line of demar- 
cation being distinctly raised, red, and unusually irregular 
in outline. The color of the diseased area is a dusky red 
and often presents a number of bullae, which rupture 



ERYSIPELAS. 87 

early leaving an abraded surface beneath. Occasionally 
portions of the skin become gangrenous. The lympathic 
glands in and about the diseased area are enlarged and 
painful, and the lymph channels are inflamed and can 
often be traced in the skin leading up to the glands as 
pink lines. You can never tell how far the erysipelatous 
process will extend if not checked, but always over a 
considerable area. The subjective symptoms present are 
heat, burning, and in a certain number of cases itching. 
There is always pain on pressure, but most acute in the 
phlegmonous form of the disease. 

The deeper structure of the skin may become involved, 
and a true phlegmonous cellulitis set up. In other cases 
the disease remains limited to the skin, and after a week 
or ten days both constitutional and local symptoms begin 
to disappear. Sometimes the redness begins to fade from 
the area first involved, other times from the margin 
of the lesion. As the redness and oedema of the 
skin disappear, desquamation takes place. The prog- 
nosis in the majority of uncomplicated cases is good. 
Most of the patients make a good recovery in about two 
weeks' time. 

Erysipelas which has passed into the phlegmonous 
stage is always more serious, and lasts a much longer time 
than the simple variety. It is always associated with con- 
siderable destruction of the deeper layer of the skin and 
cellular tissue, and with the formation of abscesses. This 
form of the disease, however, is one in which dermatologists 
are not especially interested, but belongs to the surgical 
class of cases. 

Diagnosis. Erysipelas is sometimes mistaken for derma- 
titis, acute eczema, simple erythema, herpes zoster, or an 
urticaria ; but the constitutional symptoms accompanying 



88 LECTURES IN DERMATOLOGY. 

the marked skin lesions will usually make the diagnosis 
clear to a careful observer. 

Treatment. Internally such symptomatic treatment 
as the nature of the case seems to require should be 
given. There is but one drug which seems to have 
a specific action in erysipelatous processes, and that 
is the tincture of chloride of iron. This drug seems 
not only to lessen the severity of the case, but also 
to have an abortive effect. It should, however, be 
given in large doses as frequently repeated as the 
patient's stomach can bear. Twenty minims every two or 
three hours can usually be given with good results. The 
bowels should be thoroughly opened at the commence- 
ment of the disease with a calomel purge, and afterwards 
kept open with the use of saline cathartics. The headache, 
fever, and general listlessness can usually be treated by 
frequently repeated doses of phenacetin given in a little 
whiskey. Delirium may be controlled and sleep produced 
by the use of sulfonal and chloralamid combined in 15- 
grain doses. 

The recent discovery of erysipelas coccus as a cause of 
the disease has modified very much our management of 
it, which is based largely upon the antiseptic and anti- 
bacterial external treatment. The fact that the microbes 
are found in greater abundance upon the edge of the 
inflamed surface shows that the attempt to limit the 
spread of the disease by surrounding the patch with a 
line of Higgenbottom's solution of the nitrate of silver, 
or with equal parts of tincture of iodine and pure car- 
bolic acid, was correct in principle though not always 
successful in practice. In many cases, however, it does 
check the advance of the disease, and may be used with 
great benefit. Ichthyol dissolved in collodion, two drachms 



ERYSIPELAS. 89. 

to one ounce, painted over the patch and on the surround- 
ing skin gives the best result. This application may be 
applied every second or third day. It not only prevents 
the spread of the disease, but in many cases lessens the 
severity of the local symptoms and hastens a speedy 
cure. In some cases ichthyol is borne better by the skin 
if applied either pure or mixed with lanolin in equal 
parts. Before this is applied all the neighboring mucous 
membranes and skin should be cleansed with a concen- 
trated solution of salicylic acid, then not only the red- 
dened skin but the normal as well for a hand's-breadth 
around should be thoroughly rubbed for from ten to fif- 
teen minutes with this ichthyol ; this rubbing should be 
as thorough as the pain will admit. The drug is in this 
way absorbed, and seems to act as an antiseptic in de- 
stroying the coccus. Over the whole of this area a 
layer of absorbent gauze moistened with a solution of 
boracic acid is spread, and this dressing covered with a 
thick sheet of non-absorbent sterilized cotton. This 
dressing should be changed daily. 

Occasionally, when other means fail to arrest the spread 
of the disease, a band of adhesive plaster tightly applied 
around the margin of the lesion will prevent further en- 
croachment. Lately, instead of the use of adhesive 
plaster, crossed scarification of the skin has been resorted to 
with exceedingly good results. This treatment is service- 
able in either form of erysipelas, but especially in the 
simple variety. In facial erysipelas continuous applica- 
tions of ice-cold lead and opium wash will frequently be 
all the local treatment required. Relapses are common ; 
usually at the seat of the previous attack. This is espe- 
cially true when the point of inflammation is some chronic 
ulceration or lesion in the skin or mucous membrane. 



90 LECTURES IN DERMATOLOGY. 

Erysipelas sometimes exercises a curative influence 
upon certain pathological formations, as sarcomatous 
tumors. In some cases these tumors have been inocu- 
lated with the erysipelas coccus with a curative result. 
The experiment is always dangerous, and should not be 
done without due appreciation of the severity of this 
method of treatment, for St. Anthony's fire not infre- 
quently burns unto death. 

ERYTHEMA. 

Under the general term erythema may be considered 
erythema simplex, erythema multiforme, and erythema 
nodosum, but it is to the first of these I now wish to call 
your attention. 

Pathology. The disease consists of an active hyperae- 
mia of the papillary layers of the skin, causing a dilatation 
of the blood-vessels, increased circulation and swelling of 
the skin, usually without exudation. 

Etiology. The trouble may be due to local irritation 
applied to the skin in the form of heat, cold, or irritating 
substances, or to some systemic disturbance. Gastro- 
intestinal disturbance will frequently cause an erythema, 
as will ingestion of some drugs, as quinine, antipyrine, 
and ipecac. Certain constitutional diseases, as roseola 
and scarlet fever, have erythema of the skin as one of the 
most marked symptoms, but these diseases properly be- 
long to the exanthemata. Frequently an erythema will 
appear without any apparent cause. 

Symptoms. In systemic erythema constitutional symp- 
toms are often present, but depend very largely upon the 
cause of the disease. In a large number of diseases gen- 
eral malaise with gastro-intestinal disturbance will precede 
the attack by a few hours, but in other cases the first 



ERYTHEMA. 9 1 

symptoms are those produced by the eruption itself. The 
first local symptom which usually attracts the patient's 
attention is a slight itching or burning in that portion of 
the body to be affected. Soon afterward the disease 
usually appears in patches of irregular shape, very little 
if at all elevated, bright-red in color, disappearing on 
pressure, but returning when the pressure is removed. 
The affected skin is hotter than normal, and hyperaes- 
thetic. There is no well-defined line of demarcation, the 
color of the patch varying accordingly in the normal skin. 
The patches are not usually larger than the palm of 
the hand, but may become much larger by uniting with 
other patches. But a small area of the body may be 
affected, or the disease may be quite general, nearly cover- 
ing the body. The diseased areas are most frequently 
met with on the abdomen and thighs. 

Course. The disease usually lasts but a few hours to a 
day or two, and disappears without desquamation, al- 
though it may follow if the hypersemia has been very 
active. Relapses or return of the disease are common. 

Diagnosis. You will often have great difficulty in diag- 
nosing this simple erythema of the skin from the rash of 
scarlet fever. The mistake is often made, and I have no 
doubt that in nine cases out of ten when you hear of a 
patient having had scarlet fever twice that one of the 
attacks was nothing worse than a simple erythematous 
eruption. The other diseases for which it may be mis- 
taken are erythematous eczema and erysipelas. 

Treatment. I should advise you in the treatment of 
this simple affection to begin with an active purgative, 
either calomel or castor oil, and put your patient on a 
bread-and-milk diet for a few days. Acetate of potash 
or citrate of magnesia in 20-grain doses may be given 



0,2 LECTURES IN DERMATOLOGY. 

before each meal. The external treatment consists of 
the application of soothing and cooling lotions, or pow- 
ders. If the disease is very extensive a bran bath may 
be given and then flour dusted over the surface. If 
limited in area, a calamine lotion or a lead and opium 
wash may be applied continually with very happy 
results. 

ERYTHEMA INTERTRIGO. 

Very closely allied to a simple erythema, yet taking on 
some of the character of an eczema, is a very common 
disease, occurring most frequently in young children, 
called intertrigo, or erythema intertrigo. 

Pathology. Like simple erythema, it is a hyperaemic 
affection of the skin, but one associated with a serous 
exudation, causing a maceration of the epidermis and an 
abraded surface as a result. 

Etiology. The disease is most frequently the result of 
heat, moisture, and friction, especially when combined. 
It may, like a simple erythema, result from some stomach 
or bowel disorder, or in infants as a result of teething. 

Symptoms. The disease usually makes its appearance 
suddenly, and occurs most frequently in fat people and 
infants. It occurs chiefly in those parts where the folds 
of the skin come in contact, and where moisture is pres- 
ent, as in the axilla, about the groins or nates, and under 
the breasts. The skin first becomes chafed, and feels hot 
and sore. It then becomes bright red in color, the sur- 
face abraded and moist, and secreting an acrid fluid. The 
abraded surface is considered by some due to friction, and 
by others to an exudation under the epidermis causing 
its exfoliation. The discharge is very irritating, and will 
cause the extension of the disease to the surrounding 



ER V THEM A M UL TI FORME. 



93 



skin. The affected skin becomes very sensitive and then 
painful, swollen, and hot, showing the presence of active 
inflammation. 

Course. The disease, if properly treated, usually recov- 
ers rapidly, but, if left to itself, lasts for a long time and 
may interfere with the general health. Relapses are 
common. 

Diagnosis. This form of erythema must be diagnosed 
from acute eczema, which it very closely resembles, and 
from tinea cutis or eczema marginatum, a parasitic affec- 
tion which attacks localities where we usually find inter- 
trigo. 

Treatment. Attention should be paid to the diet and 
bowels ; the affected skin should not be washed more 
often than is absolutely necessary, but should be kept 
perfectly clean. The abraded surfaces should be sepa- 
rated from each other and kept perfectly dry. Soothing 
and slightly astringent applications should be used. After 
the affected area is thoroughly cleansed and dried, a powder 
of oxide of zinc and starch, equal parts, should be dusted 
on, then Lassar's paste or diachylon ointment spread on 
a linen cloth and applied ; this should be repeated once 
or twice a day until a cure is effected. In some cases, 
especially with infants with intertrigo about the nates, a 
5 per cent, ichthyol solution may be kept continually 
applied and acts like a charm. 

ERYTHEMA MULTIFORME. 

Another form of erythema which differs very much 
from the one we have just studied, is erythema multi- 
forme. 

Pathology. Erythema multiforme is an exudative in- 



94 LECTURES IN DERMATOLOGY. 

flammation of the skin, closely resembling in some 
particulars urticaria, and in others herpes, and it is 
doubtless the result of some vaso-motor disturbance. 
Like the lesions of erythema simplex, the redness dis- 
appears on pressure, but returns when the pressure is 
removed. 

Etiology. This affection is most frequently seen in the 
spring and fall of the year. It is perhaps most fre- 
quently the result of rheumatism, but also may accom- 
pany digestive disturbances. It is not infrequently a 
complication of some chronic uterine disease, or other 
chronic, inflammatory conditions of the genito-urinary 
organs. 

Symptoms. The disease makes its appearance in a num- 
ber of different forms with a different variety of lesions, 
which have given rise to various terms used to express the 
clinical conditions and features presented. The lesions 
present themselves in the form of erythematous patches, 
in papules, and in tubercles. 

I. Erythematous forms. When the lesions are in the 
form of erythematous patches they nearly always present 
themselves in some peculiar configurations, which give 
rise to the terms erythema annulare, erythema iris, and 
erythema marginatum. 

Erythema annulare consists of circular, erythematous 
patches, most frequently occurring about the back and 
chest, fading at the centre and spreading peripherically. 
The circles are usually of small size, seldom more than 
half an inch in diameter, not scaly, but very chronic in 
their course, thus differing from ringworm for which they 
are often mistaken. 

Erythema iris. Occasionally the disease presents itself 
in a series of concentric rings, which are found possessing 



ERYTHEMA MULTIFORME. 95. 

variegated colors, as red, yellow, blue, etc., to which the 
term erythema iris is given. This form is doubtless 
closely related to herpes iris, there being more exudation 
in the latter disease producing herpetic vesicles on the 
erythematous rings. 

Erythema marginatum. When these erythematous 
patches spread over a considerable surface, having a 
sharply defined, irregular serpentine border, the disease 
is then termed erythema marginatum. As the redness 
disappears at the centre, this form of the disease often 
appears as irregular red bands. 

II. Papular form. The papular variety is that affec- 
tion originally described by Hebra as erythema multiforme. 
The lesions maybe either distinctly papular or tubercular, 
the latter to be viewed simply as an exaggerated form of 
the papular variety. This form of the eruption is almost 
always symmetrical, and is especially liable to attack the 
backs of the hands, wrists, neck, and feet, but seldom 
occurs on the trunk. The disease begins as little red- 
swellings in the skin, accompanied by some pain and 
burning. The color soon becomes a dusky red or viola- 
ceous, and afterwards yellowish, disappearing but slowly 
on pressure. The lesions are elevated, flat, circular or 
oval in shape, and vary in size from a pea to a half dollar. 
They occur in groups, and last from ten days to three 
weeks, but relapses are common. As the lesions disap- 
pear they often fade first at the centre, leaving circles or 
segments of circles. There is some desquamation. Oc- 
casionally vesicles or bullae form on these lesions, giving^ 
rise to the term erythema bullosum. The subjective 
symptoms are not so severe, notwithstanding the angry 
appearance of the lesions, there being but slight burning 
and itching present. Some slight constitutional symptoms 



g6 LECTURES IN DERMATOLOGY. 

are frequently present, as fever, headache, digestive dis- 
turbances, and pain in the joints. 

Diagnosis. As the lesions of erythema multiforme ap- 
pear in many different forms it is not always easy to 
make a diagnosis. The diseases for which it is most often 
mistaken are urticaria, pemphigus, papular eczema, pur- 
pura, erythema nodosum, and dermatitis herpetiformis. 

Treatment. Low diet, alkaline diuretics, and hot appli- 
cations of from 2 to 3 per cent, carbolic acid to the lesions 
for half an hour at a time several times a day, will usually 
hasten a cure in uncomplicated cases. If rheumatism is 
present io-grain doses of salicylate of soda seems to be 
beneficial in curing the rheumatism and the skin affection. 
If there is digestive disturbance it should be attended to. 

ERYTHEMA NODOSUM. 

Pathology. Erythema nodosum is closely allied to 
erythema multiforme, and by some dermatologists 
described as one variety of that disease. By others it is 
regarded more like a purpura rheumatica accompanied 
by an inflammatory process, which is probably nearer 
correct. The lymphatics and blood-vessels play an im- 
portant part in the disease, as the lesions are frequently 
found upon the lymph vessels, and the exudation which 
enters the inflammatory area of the skin is usually sero- 
hemorrhagic. 

Etiology. The cause of the disease is not known, but 
occurs most frequently in rheumatic patients, and in those 
especially who are anaemic and debilitated. The disease 
is more common in females than males, and in young 
adults. It is most frequently met with in the spring 
of the year. 



ERYTHEMA NODOSUM. 97 

Symptoms. This skin disease is usually ushered in with 
some constitutional symptoms, as fever, headache, and 
pains in the joints. After these symptoms have lasted 
two or three days nodes make their appearance on the 
extremities, almost always over the tibia. These nodes 
vary in size from a hickory nut to a small egg, and are 
usually oval in shape. They are very firm to the touch 
and at first red in color, but afterwards a variegated yellow, 
greenish, or bluish in tint, looking very much like a con- 
tusion, such as would be produced by a kick. The color 
does not disappear on pressure, showing that there has 
been some hemorrhagic exudation in the skin, which 
undergoing chemical changes produces the different 
colors. The lesions often have a shiny, tense look, as if 
suppuration were going to take place, but it never does. 
These nodes are somewhat tender on pressure, and ac- 
companied by some burning sensations. Purpuric spots 
are also sometimes present. The lesions appear in groups ; 
not more than eight or ten are usually present at one time. 
Each node lasts from two to four weeks, and disappearing 
leaves some pigmentation which is slowly absorbed. New 
growths are apt to appear before the old ones are gone. 
Each crop is preceded by some febrile disturbance. 

Diagnosis. Erythema nodosum must be diagnosed 
from gummous syphilide, bruises, purpura or scurvy, 
urticaria, abscesses, and erythema multiforme. 

Treatment. Iron and ergot are indicated in almost all 
cases. They seem to- hasten the resolution of the nodes 
and prevent relapses. In cases complicating rheumatism 
salicylate of soda should always be given. Local applica- 
tions do very little good. Hot, alcoholic fomentations 
applied for two or three hours every day seem beneficial 
in hastening resolution. The bowels should be kept 



98 LECTURES IN DERMATOLOGY. 

thoroughly open and the kidneys active by the use of 
salines. The following prescription given in teaspoonful 
doses every three hours has been very beneficial in my 
hands : 

$ Antipyrin gr ii 

Pot. iodid., 

Pot. bicarb aa gr iv 

Pot. acet gr viii 

Tinct. hyoscyami, 

Tinct. colch. sem aa lUiv 

Alcohol tt^x 

Glycerini 3 ss 

Aq. menth. pip ad 3 i 

m 



LECTURE VII. 

FEIGNED SKIN DISEASES, FURUNCULOSIS, HERPES, 
HERPES ZOSTER, AND HYPERIDROSIS. 

FEIGNED DISEASES OF THE SKIN. 

Gentlemen : 

I wish to call your attention to-day to certain conditions 
of the skin which are usually described as feigned dis- 
eases of the skin, and are often very difficult to diagnose. 
It must be remembered that various diseases of the skin 
may be closely simulated by artificial means, and that such 
deception may be kept up for months. In some cases, as 
skin diseases occurring in prisoners, malingerers, and 
others in whom we might suspect the artificial produc- 
tion of skin diseases, close watch may be rewarded by dis- 
covery of the deception ; but in other cases, happening as 
they frequently do among hysterical females of the better 
classes, the difficulties of diagnosis are heightened by the 
fact that the feigned eruptions may be caused by a sort of 
automatic, insane impulse without any possible object. 
These you can readily understand will be most difficult to 
detect. To aid, however, in the diagnosis, in the first 
place the disease is almost always anomalous in the time, 
place, and manner of its appearance, and in the course in 
which it runs. In the second place, it almost always shows 
some signs of having been artificially produced, and is 
usually in a position easily accessible to the manipulator. 
The face, forearms, chest, lower limbs, and mammary 
99 



lOO LECTURES IN DERMATOLOGY. 

region are most apt to be the seat of the eruption. Care- 
ful inspection of the lesion will very frequently show 
along the edges some trace of the irritant used, or the 
mechanical irritant applied. Among the diseases most 
frequently feigned are, first : 

Alopecia areata, which may be simulated by plucking 
the hairs from a circumscribed area, but close examination 
will show the result of this violent operation, and after a 
few days' watchfulness you will be able to detect the new 
hairs springing up before they are long enough to be 
epilated. 

Bromidrosis is also frequently feigned, especially among 
the French and Germans. In France bromidrosis will 
prevent a soldier from entering the army, and in Germany 
foul-smelling feet is a legal ground for divorce. It is 
usually practised by the inunction of animal oil, asafceti- 
da, decayed fish, or cheese. Frauds of this sort are 
easily detected if the suspected person can be kept under 
surveillance for a short time. First using a disinfectant — 
as permanganate of potash, and then causing the patient to 
sweat freely by the use of hot air, will immediately show 
that the perspiration has no odor whatsoever. Besides it 
is also noticed that bromidrosis of the feet is almost al- 
ways accompanied by a macerated appearance of the 
soles, which is never present where the disease is feigned. 

Dermatitis is perhaps more frequently produced by 
artificial means than any other of the eruptions. It is 
nearly always the result of tearing the skin with the nails, 
or by continual friction with the finger tips. This will 
produce lesions of the skin which appear very much like 
herpes, or like neurotic excoriations. Sometimes painful 
erythematous patches are produced in this way, which are 
succeeded by exudation on the surface of serum and 



FEIGNED DISEASES OF THE SKIN. IOI 

sero-pus, making the lesions appear very much as a 
case of eczema. 

Vesicular and pustular eruptions are usually produced 
by the application to the skin of some irritant, croton oil, 
mustard, and turpentine being the most frequent sub- 
stances used. All these substances give rise to confluent 
vesicles, becoming rapidly purulent or vesico-purulent, 
which may be readily mistaken for eczema, to papular 
eruptions, or urticaria. The latter is occasionally simu- 
lated by the application of nettles or by the ingestion of 
certain substances which the patient knows will produce 
eruption. As these eruptions are transitory, hysterical or 
malingering persons would hardly be likely to take the 
trouble f or a result lasting so short a time. 

Of all lesions of the skin ulcers are more frequently 
produced by malingerers than any other. Many substances, 
such as cantharides, nitric acid, and sulphuric acid, when 
applied to the skin and allowed to remain for some time, 
will produce an ulcer which will last for a time. These 
ulcers when having a tendency to heal will be kept in- 
creasing in size by continued application of the irritating 
substance. 

Erythematous patches, appearing at first glance very 
much like erysipelas, may be produced by applications of 
thapsia and numerous other substances, but as the erup- 
tion lasts for so short a time it is not frequently resorted 
to. The treatment of all these classes of cases, of course, 
is to prevent the patients from thus abusing themselves. 

FURUNCULOSIS. 

A disease which I hardly need introduce to your notice, 
as many of you have had its acquaintance thrust upon 
you, is furunculosis or boils. 



102 LECTURES IN DERMATOLOGY. 

Pathology. A cutaneous boil always has its seat in the 
deeper layers of the skin, and has its starting-point either 
in a sebaceous gland, sweat gland, or hair follicle. The 
inflammation is an active one, and always accompanied 
with not only the production of pus, but also some cen- 
tral necrosis of the skin called the core, which is composed 
of the tissues of the gland in which the boil originated 
and the structure about it. The inflammation is always 
circumscribed about the central core, the inflammatory 
products being infiltrated into the tissues of the skin. 
After the necrotic tissue is separated from the living struc- 
ture by process of suppuration it is cast off, and the inflam- 
matory products about it are absorbed. A slight scar 
remains, showing the seat of the destructive process. 

Etiology. Although it is reasonable to suppose that 
boils are produced by a micro-organism, which gains 
access to a gland and there sets up an inflammatory 
process, there are certain conditions which must be 
present to admit of this pathological change. Certain 
lowered conditions of the system are seen in diabetes, 
anaemia, continued fevers, general debility, chronic metal- 
lic poisoning, etc. Boils may also result from the use of 
improper food and ingestion of certain drugs, as the bro- 
mides and iodides. They sometimes apparently result 
from local causes, as friction, contusions of the skin, etc., 
but it is doubtful if injuries of this nature would produce 
the disease if there was no predisposition. Boils some- 
times occur in epidemics, thus strengthening the theory 
that the process is the result of bacterial infection. 

Symptoms. Boils attack both sexes and at any time in 
life, but young adults are more susceptible to the disease. 
There are usually no more than two or three lesions pres- 
ent at one time, but these lesions are very apt to occur in 



FURUNCULOSIS. IO3 

successive crops, so that the patient may not be entirely 
free from these " comforters " for many months. Any 
portion of the body except the palms or soles may be 
the seat of the disease, but certain portions of the body 
are more apt to be affected than others. Boils occur more 
frequently upon the neck, shoulders, and buttocks than all 
other portions of the body. When several lesions appear 
simultaneously they are usually grouped about the same 
locality, but always remain discrete. Sometimes a number 
of lesions are scattered all over the body, when the term 
" general furunculosis " is used. This form of the disease 
is very rare, but one of the few skin diseases mentioned 
in the Bible, for " Job was sore # afflicted with boils from 
the crown of his head to the sole of his foot." Each lesion 
first begins as a little red spot in the skin, which is hot 
and accompanied with burning or itching, painful on 
pressure. Within twenty-four hours it increases in size, 
becomes raised above the surface of the skin in the form 
of a papule, and presents considerable induration. The 
summit of this papule soon becomes pustular, and in the 
centre of the pustule a hair will frequently be seen to 
penetrate, while the skin about it becomes a purplish red 
color, shiny, indurated, and very painful and tender. The 
pustule if opened at this stage will secrete only a little 
pus, or serum, or blood, but the centre of the indurated 
skin will present a yellowish, neurotic mass, due to the 
death of its central portion. This mass is called the core. 
Within a day or two suppuration takes place about this 
core separating it from the living tissues, and the dis- 
charge of pus becomes very free. At the end of five days 
to a week the core is discharged with the pus, the indu- 
ration begins to subside, the discharge of pus becomes 
less, and healing takes place leaving a small scar, the result 



104 LECTURES IN DERMATOLOGY. 

of the destructive process. The amount of throbbing 
pain experienced at the seat of the lesion is often very 
great. Occasionally the boil does not mature, there being 
little or no suppuration or formation of a core, simply a 
hard, painful, deep-seated, indurated swelling in the skin, 
which disappears very slowly. This condition is usually 
spoken of as a blind boil. 

Diagnosis. There is seldom any difficulty in recog- 
nizing a boil, as both the lesion and symptoms are so well 
marked. It is possible, however, to confound it with 
a carbuncle (anthrax), or with a malignant pustule. It 
is also possible to mistake a boil for a large pustular syphi- 
lids 

Treatment. Boils if treated in time, or before the core 
forms, may often be aborted. If the inflammation is 
about a hair follicle the hair should at once be re- 
moved. Counter-irritation and strong antiseptics are the 
local agents you must rely upon. One grain of bichloride 
of mercury to an ounce of flexible collodion painted over 
the lesion may abort it. Carbolic acid and tincture of 
iodine in equal parts has given me the best results in 
aborting a beginning boil. The point of a sharp-pointed 
wooden tooth-pick should be dipped in this solution and 
thrust deeply into the centre of the lesion, and then 
diachylon ointment applied. In some cases this treat- 
ment seems to be exceedingly beneficial. The actual 
cautery applied to a boil at its very beginning will some- 
times abort it. 

It is often customary among patients who are afflicted 
with styes, which are really boils affecting the eyelids, to ap- 
ply a hot ring, which acts slightly as a caustic application 
and may act as an abortive agent. Internal use of a calomel 
purge followed by frequently repeated doses of sulphide 



FURUNCULOSIS. IO$ 

of arsenic or calcium seems to prevent the formation of 
boils. This is about all we can do to prevent the for- 
mation of these lesions when seen in time. When once 
suppuration begins and the core forms, we should hasten 
its separation by the application of heat in the form of 
poultices. I know that poulticing is now considered by 
many as old-fashioned, but I know of no better appli- 
cation to make to hasten the maturation of a boil than a 
hot, old-fashioned flaxseed poultice, sprinkled over with 
laudanum. These poultices should be applied continually 
until the slough separates, when under protective dressing 
the lesion will heal rapidly. 

The surgical treatment of a boil is to open in and to 
apply wet, antiseptic dressing. The one good which can 
result from opening a boil is to relieve the tension and 
congestion of the skin, and in this way to relieve the pain 
and hasten the separative process. In some cases when 
the tension of the skin is great the knife should be freely 
used, and in all cases where the pus is confined in the 
skin. 

Constitutional treatment. The general health of the 
patient should always be considered and treated accord- 
ingly. Tonics are frequently called for, and one deserving 
of great praise in the treatment of debilitated conditions 
associated with the production of boils is Fellows' syrup 
of hypophosphites. The sulphides, especially of arsenic 
and calcium, certainly lessen the tendency to the recur- 
rence of boils if given for some time in large and fre- 
quently repeated doses. Bathing the skin once a day 
in some antiseptic solution, as bichloride of mercury 
1:1000, on the theoretical grounds of destroying all 
disease germs which may be actively engaged in producing 
boils, has in some cases been satisfactory. 



106 LECTURES IN DERMATOLOGY. 

HERPES. 

We come now to the consideration of a class of disease 
which is distinctly vesicular in character, and described 
under the general term of herpetic eruptions. The ones 
which I wish to especially call your attention to are known 
as herpes, the most common examples of which are herpes 
facialis, herpes progenitalis, and herpes zoster. 



HERPES SIMPLEX. 

Pathology. The vesicles in herpes simplex are formed in 
the same way as the vesicles in vesicular eczema, and as 
a result of an exudative inflammation, which is probably 
due to some nerve disturbance, the pathology of which is 
not at all well understood. 

Etiology. Exposure to cold, digestive disturbance, fever- 
ish conditions, and external irritants are the most frequent 
causes of herpes. 

Symptoms. The eruption is often preceded by malaise 
and fever, or, as is often the case, it occurs in the course 
of some severe febrile condition, as typhoid fever. The 
first local symptom is a heat and burning in the place 
where the eruption is to make its appearance. A few 
hours after, a group of vesicles, usually from four to ten in 
number, make their appearance upon a reddened surface. 
They are usually from a pin-head to a split pea in size, 
discrete at first, but may become confluent. Their con- 
tents, at first clear, soon become cloudy and somewhat 
purulent, which after a few days dry into small brownish 
crusts. These vesicles may or may not rupture sponta- 
neously, but, if broken, an excoriated and exuding surface 
is exposed, which crusts over and heals without leaving 



HERPES. 107 

a scar. A number of groups of these vesicles may occur 
at one time, or follow each other. 

HERPES FACIALIS. 

When this eruption occurs on the face we often find it 
about the borders of the lips, where it is commonly known 
as fever- or cold-sores. The vesicles rupture spontaneously 
owing to the maceration soon after forming, so they often 
appear from the start as excoriated patches, which crust 
over and heal in a few days. When the vesicles appear 
elsewhere on the face, as about the alae of the nose, they 
are less apt to rupture, and remain as such, drying up and 
forming a scab which falls off in a day or two. 

HERPES PROGENITALIS. 

This variety of herpes in the male occurs generally on 
the inner surface of the prepuce, and in the female on the 
inner surface of the labia majora. The lesions, however, 
are not limited to these regions. It is a disease of youth 
and middle age, seldom occurring after forty, except in 
women at menopause, and, with this exception, it is 
almost always found in persons who have suffered some 
time previously with some venereal disease, especially 
gonorrhoea. There is nothing peculiar about the vesicles. 
They are preceded by pain and tenderness, appear on a 
reddened surface, usually in clusters of four or five ; they 
rupture easily through maceration, leaving superficial 
ulcers covered with a whitish deposit, and may heal in a 
few days. Relapses are common. 

Diagnosis. Great care must be taken in diagnosing these 
little ulcers from true chancroids. The following are 
some of the points of differential diagnosis between these 



108 LECTURES IN DERMATOLOGY. 

two diseases, for it is of great importance that you should 
be able to distinguish between them : 

Herpes always begins as vesicles, chancroids as ulcers ; 
herpes appears in groups, chancroids do not ; herpes is 
always multiple, chancroids single or few in number ; the 
lesion of herpes is very superficial, those of chancroids 
quite deep ; herpes lasts but a few days, chancroids for a 
week or longer ; the lymphatic glands in herpes are not 
much enlarged, in chancroids they are enlarged and fre- 
quently suppurative ; repeated attacks of herpes are 
common, no relapses from chancroids; herpes usually 
preceded by burning and itching, and no premonitory 
symptoms to chancroids ; herpes not contagious or auto- 
inoculable, chancroids very contagious. It is also neces- 
sary to diagnose simple herpes from herpes zoster, vesicu- 
lar eczema, and hydroa. 

Treatment. The herpetic vesicles should be protected 
from rupturing by an application of some soothing or 
drying ointment, as the following: 

fy Camphorae . . . . gr. xv 

Ung. aq. rosae . . . . § i 

When they have ruptured, the oxide of zinc ointment, 
with half a drachm of camphor to the ounce, is an excel- 
lent remedy to use, especially about the face. When 
occurring about the genitals the part should be bathed 
frequently with hot water, dried thoroughly, and calomel 
dusted over the lesions. In some cases, the following 
ointment is especially serviceable : 

$, Hyd. ammon. . . . . 3 ss 

Hyd. chlor. mit 3 iss 

Ung. aq. rosae . . . . ad § i 

m 



HERPES. IO9 

In other cases an astringent lotion, such as — 



]$ Zinc, sulph. . 


gr. v 


Spt. lavandulae comp. 


3ss 


Aq. rosae 


. ad 3 i 


m 





kept continually applied on a little cotton — will be found 
very useful. Recurrent attacks occurring in persons with 
a long prepuce, circumcision should be performed. 

HERPES ZOSTER. 

Herpes zoster, although properly classed as a neurotic 
skin affection, will be found more conveniently considered 
by us among the vesicular eruptions. 

Pathology. As the disease is one of neurotic origin, there 
is generally found an inflammatory condition of the nerves 
supplying the portion of skin affected, or of the ganglionic 
centres from which these nerves are derived. The spinal 
ganglia are the ones found most frequently diseased and 
softened. The disease is, however, not infrequently asso- 
ciated with disease of the brain or spinal cord. The 
cutaneous lesions are the same as those found in simple 
herpes, and formed in the same way. The papillae are 
considerably enlarged, due to cell infiltration, and may 
appear as papules. The nerves in the skin are swollen, the 
medullary layer softened, and the axis-cylinder increased 
in size. 

Etiology. Malarial poisoning probably causes more at- 
tacks of herpes zoster than all other causes put together. 
Sudden changes of temperature and exposure to severe 
cold may be the exciting cause. Injury to the nerves or 
ganglionic centres may be followed by an attack of herpes 
zoster, as may lesions of the brain and spinal cord. Some 



IIO LECTURES IN DERMATOLOGY. 

drugs have been known to produce the disease, especially 
arsenic. 

Symptoms. Herpes zoster, or shingles, as the disease is 
more commonly known, usually begins by neuralgic pains 
in the region to be affected for a day or two before the 
eruption makes its appearance, which in some patients 
are very severe, while in others, especially in children, 
they do not amount to much. The pains may be accom- 
panied by some fever. Next there appear, at the seat of 
the pain, several red patches of skin following the course 
of some nerve trunk. Upon this inflamed area soon 
appear groups of papules or vesico-papules, which have a 
tendency to form in groups. These lesions, within a day, 
however, become vesicles about the size of a split pea, at 
first discrete, but if crowded closely together soon become 
confluent. New inflammatory areas make their appear- 
ance from day to day, and upon them new groups of 
vesicles, until about the eighth or tenth day the disease 
is at its height. The vesicles, as a rule, do not rupture 
spontaneously, but are frequently broken by rubbing or 
violence, leaving a superficially ulcerated surface, which 
scabs over. The vesicles first contain a clear serum, 
which afterwards becomes cloudy and thick, often puri- 
form, and sometimes hemorrhagic. These vesicles usually 
dry up in about a week's time, forming brownish crusts, 
which drop off, leaving a reddened surface which gradually 
disappears without scarring. As new groups of vesicles 
continue to appear for about ten days, we find them in all 
stages of development. The neuralgic pain continues 
during the formation of these lesions, and, not uncom- 
monly, for some time after they disappear. The disease 
may attack any portion of the body, and almost invariably 
follows some nerve trunk. It has a decided preference to 



HERPES. 1 1 1 

follow the course of some intercostal nerve, next to these 
the brachial and cervical plexus. The eruption is almost 
always unilateral, although occasionally bilateral. The 
popular belief, that if the disease is bilateral and entirely 
encircles the body death will follow, is erroneous. 

Course. The disease usually ends in complete recovery 
in about two or three weeks, but occasionally deep ulcera- 
tion takes place, which requires a long time to heal, leaving 
scar tissue. Relapses are common. 

Diagnosis. Herpes zoster must be distinguished from 
simple herpes, erysipelas, vesicular eczema, and herpes 
iris. 

Treatment. The treatment should be both constitu- 
tional and local. Quinine seems to be the only one 
remedy par excellence, and should be given in from 
1 5-to-20-grain doses a day. The disease is frequently 
malarial. Perhaps this will account for the bene- 
ficial action of the drug. As the neuralgic pains are 
frequently very great, it had better be combined with 
either antipyrine or morphine. Quinine will frequently 
abort an attack, or greatly lessen its severity. To prevent 
recurrent attacks, which frequently come on at regular 
intervals each year, arsenic should be given in the form of 
Fowler's solution, three to five drops after meals. This 
may be given for several weeks before the expected 
attack. If you see the disease at the commencement of 
the eruption, or before the vesicles become purulent, the 
best local treatment consists of painting the affected area 
over with flexible collodion, in which are incorporated ten 
grains of morphine to the ounce. This not only eases the 
pain, but hastens absorption of the products of inflamma- 
tion. You should be careful not to make this application 
if the vesicles are puriform, for the confined pus may set 



112 LECTURES IN DERMATOLOGY. 

up an ulcerating process which may be very extensive. In 
this stage of the disease, or if the vesicles have been rup- 
tured extensively, it is much better to apply some dry and 
soothing antiseptic ointment, such as Lassar's paste or 

I> Camphorne 3 ss 

Ung. zinc, ox ad 3 i 

which not only lessens the inflammation, but dries up the 
discharges, prevents the formation of pus, and heals the 
lesions. Should the neuralgic pains continue after the 
local symptoms have disappeared, the use of arsenic 
internally and electricity along the course of the affected 
nerves gives the best result. 

HYPERIDROSIS. 

I will say but a few words to you in reference to a 
disease of the sweat glands, the most important symptom 
of which is excessive sweating, called hyperidrosis. 

Pathology. The disease, so far as the sweat glands 
themselves are concerned, is purely a functional one, as 
the gland structure itself does not seem to be altered at 
all. The disease is undoubtedly one of the nervous 
system, but no organic lesions have ever been discovered 
which could be considered at all direct. 

Etiology. The secretion of the sweat glands is under 
the control of the vaso-motor system of nerves, whose 
nerve centre is in the spinal cord, just below the medulla. 
Any nerve lesion, disturbance of the nervous system, 
nervous impressions, or physiological action, as that 
caused by the ingestion of certain drugs, acting on the 
vaso-motor nerves or sweat centre, may affect the func- 
tional activity of the sweat glands. Thus, organic lesions 
of the brain and spinal cord, nervous debility, enervating 



HYPERIDROSIS. 1 1 3 

diseases, severe mental impressions, shock, drugs like 
pilocarpin, are frequent examples of the cause of hyperi- 
drosis, either general or local. There are, however, many 
cases of local sweating especially, where no cause can be 
discovered, and must be considered as directly due to 
functional disturbance in the sweat centre or vaso-motor 
system. There is often found an hereditary predisposi- 
tion, but this is also frequently absent. 

Symptoms. The disease may be either local or general, 
but it is only the local sweating to which I wish to call 
your attention to-day. Local sweating may occur on any 
portion of the body, but it is most frequently encountered 
upon the soles of the feet, palms of the hands, the axilla, 
the face, or the genitals, and may be limited to one side 
of the body. This excessive sweating may occur con- 
tinually or in paroxysms, but even when continually it is 
worse at certain times than at others. The amount of 
secretion may be moderate or excessive, so excessive at 
times that drops of sweat will collect every few seconds, 
and roll off the surface. In one case I remember having 
collected a drachm of sweat from one hand alone in ten 
minutes. When so excessive as this, the sweating is 
usually limited to a small area. 

Usually other portions of the body, except the affected 
area, are supplied with sweat glands with normal functional 
activity, but in other cases the glands are either diminished 
in number, or their secretion is diminished. As the skin 
of the part affected is continually wet, it becomes yellow- 
ish or whitish in color, has a soggy appearance, with the 
surface temperature usually below normal. The macera- 
tion of the epidermis and the accumulation of the secre- 
tion, which undergoes a decomposition, often give rise to 
a most disagreeable odor, called bromodrosis. Bromodrosis 



114 LECTURES IX DERMATOLOGY. 

is, however, frequently a disease occurring by itself, and 
not associated with hyperidrosis. Very frequently the 
macerated skin peels off, leaving the tender skin exposed, 
making the part very tender. This is especially apt to 
occur about the feet, making walking very painful. Some- 
times the subjective symptoms in the part, as tingling, 
pricking, or neuralgic pains, are quite pronounced, but 
are not usually present. 

Course. The disease is usually a chronic one, lasting 
for years. Although it may improve for a time, it is 
very apt to return. It is not very amenable to treat- 
ment, and some cases do not seem to improve at all 
under it. 

Treatment. In local sweating constitutional treatment 
does not seem to meet with the same success that it 
frequently does when the disease is general, for in the 
latter case the general health is very much run down, and 
tonic treatment is called for, but here tonics are not often 
required. Strychnine, ergot, and belladonna or atropia 
are the three remedies which may be used internally with 
advantage. If atropia is used, it had better be given 
hypodermically in or near the affected area in small doses 
once a day. Locally the use of the faradic electricity 
certainly is beneficial, the positive sponge electrode, 
soaked in strong brine solution, being applied to the 
affected area, and the negative to the upper part of the 
spinal cord. Electric baths also frequently give a good 
result. Electricity should be applied every two or three 
days, and continued for some time. In the way of drugs 
for external use salicylic acid, rubbed into the part and 
kept constantly in contact with it, is the best treatment 
that I can suggest. Diachylon ointment, containing 10 
per cent, salicylic acid, is also very serviceable kept con- 



HYPERIDROSIS. 1 1 5 

tinually applied. Astringent baths of alum or tannic 
acid may be applied, but they are not usually followed 
by any permanent result. Very hot applications of the 
following — 

B Plumbi acetat 3 ss 

Ac. acetic, 

Alcohol aa § ss 

Aquae ad § viii 

m 

may be applied every night for half an hour before the 
salicylic acid or diachylon ointment is used. This treat- 
ment should be continued for several weeks, and may 
be followed by a cure ; but your prognosis should be 
guarded, for in a short time the trouble is apt to return. 



LECTURE VIII. 

HYPERTRICHOSIS, IMPETIGO, lAfPETIGO CONTAGIOSA, 
KELOID, KERATOSIS PILARIS, LENTIGO, LET CO- 
DERMA, LICHEN PLANUS, AND LICHEN TROPICUS. 

HYPERTRICHOSIS. 

Gentlemen : 

Under the term of hypertrichosis, or hirsuties, I wish to 
call your attention to abnormal growth of the hair, either 
upon regions where no hair usually grows, or where it is 
ordinarily found. The abnormal growth of hair is a very 
common occurrence in connection with moles, when the 
disease is known as naevus pilosus. The treatment of 
this affection is limited to cases where the abnormal 
growth is confined to small areas. 

Undoubtedly the best treatment is by electrolysis. A 
galvanic battery of from eight to twelve cells will produce 
a strong enough current to destroy the follicles. A very 
fine gold-plated needle should be connected with the 
negative pole, while the positive pole with the sponge 
electrode should be held by the patient. The needle is 
to be introduced at the side of the hair into its follicle, 
and allowed to remain there until the hair is loosened, 
which usually takes about ten seconds. While the cur- 
rent is passing, a little fluid mixed with bubbles of air 
may be seen to pass out of the follicle by the side of the 
needle The pain is very sharp, but may be lessened 
considerably by introducing and extracting the needle 
116 



H YPER TRICHOSIS. 1 1 7 

when the current is broken. It is better to let the patient 
make and break the current by grasping and letting go 
the sponge electrode. Many patients have told me that 
the pain is very much lessened when I make a strong ap- 
plication of cocaine before operating. When the follicle 
is destroyed by electrolysis the hair will never grow again. 
As the result of the treatment a dermatitis often results 
with pustulation, which lasts a few days, and until this 
subsides the agent should not be used again in the same 
area. To allay this inflammation, I have found that an 
application of hot water followed by an ointment com- 
posed of twenty grains of camphor to an ounce of water 
of roses very serviceable. Little or no scarring remains. 

The objections to this plan of treatment consist in the 
length of time it takes to effect a cure, the pain experi- 
enced by its application, the irritation and inflammation 
resulting, and the possible stimulation to increase the 
growth of the fine hairs in the neighborhood. 

Depilatories are of some service, the sulphides of the 
metals being usually employed, especially the sulphide 
of barium and sodium. Either one of these should be 
mixed with two or three times its weight of some sub- 
stance, as starch or oxide of zinc, made into a paste and 
applied to the hairy portions in thin layers for about ten 
or fifteen minutes. As soon as burning is felt in the skin 
it should be completely removed, and some bland oint- 
ment applied. These applications must be repeated from 
time to time, as they do not usually destroy the hair 
follicles. The following prescription is sometimes used 
with advantage : 

^ Powdered air-slacked lime .... 31 
Orpiment (arsenic trisulphide) . . gr. ii 



Il8 LECTURES IN DERMATOLOGY. 

This should be made into a thick paste by adding water, 
and applied to the hairy surface for fifteen minutes and 
then washed off. This application should be made at 
first twice a week, and gradually less often until the hair 
no longer grows. This treatment usually takes a year to 
effect a cure. Very little irritation of the skin results 
from the use of this agent. 

IMPETIGO. 

Pathology. Impetigo is distinctly a pustular disease. 
It is due to a circumscribed, exudative inflammation of 
the papillary layer of the skin with the formation of pus, 
which raises up both the horny and mucous layers of the 
epidermis, thus accounting for the thick walls of the 
pustule. The inflammatory process is so circumscribed 
that the lesions are not surrounded by an inflammatory 
areola. 

Etiology. It is a disease of children under ten, and is 
rarely seen in adults. It occurs often in healthy children, 
and without apparent cause. 

Symptoms. There may be some constitutional disturb- 
ance ushering in the eruption, but if present is usually 
slight. The eruption begins as pustules on erythematous 
spots. These pustules vary in size from a split pea to a 
finger nail, and are prominently raised above the skin, 
with thick walls, which are very tensely distended with 
fluid. In two or three days they reach their full develop- 
ment, when the erythema around them disappears. The 
pustules are discrete, and have no tendency to rupture or 
form in groups. There are seldom more than a dozen on 
the body at one time, and they occur most frequently on 
the face and the extremities, especially the hands and 



IMPETIGO CONTAGIOSA. II9 

feet. After the pustules reach their full development 
they are gradually absorbed or dry up, forming brownish 
crusts, which fall off, leaving a reddened surface without 
pigmentation or scar. New lesions make their appear- 
ance as the old ones dry up. When the pustules are 
ruptured they exude a whitish fluid, leaving an excoriated 
and exudative surface, which usually crusts over. These 
lesions are accompanied by few if any subjective 
symptoms. 

Course. The disease is an acute one, running its course 
in a few weeks, often without treatment. 

Diagnosis. You must be careful not to confuse this 
disease with impetigo contagiosa, which it sometimes 
resembles. It is liable also to be mistaken for pustular 
syphilide and ecthyma. 

Treatment. The lesions when fully developed should 
be opened, and their contents allowed to escape. The 
loosened epidermis should then be carefully removed, and 
some protective ointment applied to the reddened sur- 
face. Diachylon ointment, with fifteen grains of salicylic 
acid to the ounce, is a good application to use. If crusts 
have already formed they may be protected and not re- 
moved, as healing goes on very rapidly under them. As 
the disease always ends in spontaneous recovery, be care- 
ful you do not make matters worse by too active treat- 
ment. No internal treatment is necessary. 

IMPETIGO CONTAGIOSA. 

A much more common disease, similar in many respects 
to impetigo, and one which you will see quite frequently 
in your practice, is impetigo contagiosa. 

Pathology. The disease is undoubtedly contagious, and 
due to a germ or fungus. What this micro-organism is 



120 LECTURES IN DERMATOLOGY. 

has not been definitely demonstrated, as observers differ 
as to its appearance. According to Piffard and to most 
observers of the present day, the same fungoid bodies 
found in impetigo contagiosa also occur in the pustules 
and crusts of vaccinia. The disease is distinctly a cir- 
cumscribed, inflammatory one, characterized by the 
formation of vesico-pustules by raising up of the horny 
layer of the epidermis by the exudation. 

Etiology. The disease is one confined almost exclu- 
sively to children who are uncared for and uncleanly. It 
is very contagious and also auto-inoculable. It so fre- 
quently follows vaccination that Piffard considers that it 
always primarily, is the result of the inoculation from a 
vaccine vesicle or crust. The disease usually occurs in 
epidemics. 

Symptoms. There frequently is a slight febrile disturb- 
ance preceding the eruption, which usually makes its ap- 
pearance about the face and hands, and often upon other 
portions of the body. The eruption begins as isolated 
vesicles, which are flat and increase in size until they are 
as large as a finger nail, still remaining flat however. As 
they reach their full size they become sero-purulent or 
purulent. At first they are surrounded by a slight in- 
flammatory areola, which disappears when the lesions 
mature. These vesico-pustules are round or oval in 
shape, with thin, flaccid walls, often umbilicated, which 
rupture in a few days, drying in yellowish crusts, easily 
detached and looking as if they were " stuck on." These 
fall off in a few days, leaving a reddened surface beneath. 
The lesions appear in groups, usually remaining discrete, 
but sometimes running together, forming patches, and 
appearing as bullae. The disease is one of short duration, 
not lasting usually more than a few weeks, in which time 



KELOID. 121 

a number of successive crops of lesions may make their 
appearance. A slight pigmentation often remains at the 
seat of each lesion. 

Diagnosis. A differential diagnosis must be made be- 
tween impetigo contagiosa and scabies, impetigo, varicella, 
pustular eczema, and pemphigus. 

Treatment. But the mildest treatment is usually re- 
quired, as the disease is not one of long duration, and 
without treatment ends in spontaneous recovery. When 
the vesicles form they maybe opened, and the undermined 
epithelium carefully removed. The excoriated surface 
may then be treated with the following ointment : 

I£ Ung. hyd. ammon., 

Ung. zinc, ox aa § i 

m 

which not only heals the lesions, but prevents extension 
of the disease by auto-inoculation. If crusts have formed 
they may be protected by a little oxide of zinc ointment, 
as new epithelma seems to form more rapidly under them 
than it does when they are removed. In cases when re- 
lapses are frequent a 10 per cent, solution of ichthyol in 
water kept continually applied to the lesions not only 
heals them rapidly, but prevents them spreading by 
reinfection. 

KELOID. 

Surgeons perhaps more frequently than dermatologists 
are called upon to treat keloidal growths in the skin, but 
the frequency with which they are met warrant my saying 
a few words to you upon the subject. 



122 LECTURES IN DERMATOLOGY. 

Pathology. A keloid has its seat in the corium, and 
•may cause an atrophy of the other layers of the skin and 
the glandular appendages. The whole thickness of the 
corium is occupied by bands of new connective tissue 
with few cells. These bands seem to start from the blood- 
vessels, and branch out into the surrounding skin. 

Etiology. Keloid may arise spontaneously, or spring 
from the site of a scar, the result of some previous injury 
to the skin. The latter is very much the more common. 
The disease is more common in negroes than in white 
people. 

Symptoms. The disease usually begins as a small, pale 
or pink nodule, deeply seated in the skin, and growing 
very slowly. From this central point the lesion sends out 
several firm, ridge-like prolongations extending into the 
normal skin. The central portion or body is usually 
round or oval while these prolongations are narrow, giv- 
ing the lesions somewhat the appearance of a crab with 
its claws extended. In other cases the shape of the 
lesions is extremely irregular, but in all cases the outline 
is well pronounced, the disease looking as if it was set in 
the skin. The lesions are always elevated, especially in 
the centre, of firm, elastic consistence, and varying in size 
from a pea to the palm of the hand, or larger. The color 
of the surface is pinkish or purplish, smooth and devoid 
of hair. The lesions are apt to appear singly, although a 
number may be present. They usually appear about the 
sternal region, the neck, or ears, but may occur upon any 
portion of the body. There may be a little pain present, 
but usually the subjective symptoms are not at all severe. 
The disease grows slowly, but after reaching a certain 
growth remains stationary for years, occasionally under- 
going a spontaneous involution in syphilitic patients. 



KERATOSIS PILARIS. 1 23 

Diagnosis. You must not mistake hypertrophied scar 
tissue for keloid, but this is the only diseased condition of 
the skin which closely resembles it. 

Treatment. Internal treatment seems to have little 
or no effect. Mixed treatment, or Donovan's solution, 
may check the growth and lessen the size of the 
lesions. Occasionally anodynes must be given to re- 
lieve the pain. Externally lead and mercury plasters 
alone, or combined with belladonna, seem to be the only 
mild remedies having any good effect. The new growths 
may be excised or removed with cautery, but they are 
almost sure to return, and often with great rapidity, as- 
suming larger proportions than formerly. Occasionally 
good results are obtained by removing the growths by 
means of electrolysis. This plan of treatment is worthy 
of atrial in cases where the growth is disfiguring. 

KERATOSIS PILARIS. 

Pathology. A disease which is a very common one, 
and consists pathologically of an accumulation of epider- 
mic cells about the openings of the hair follicles, forming 
conical-shaped papules, is keratosis pilaris. 

Etiology. As the disease occurs most frequently in 
those who do not bathe often, the lack of cleanliness may 
be considered in some cases as the cause ; but it does oc- 
cur also in those who bathe every day, so that this cannot 
be considered as the only one. What other factors may 
produce the disease we do not know. 

Symptoms. The lesions are pin-head in size, and occur 
chiefly on the extensor surfaces of the extremities, espe- 
cially about the thighs, but also occur on the trunk. They 
are conical in shape, grayish or dull red in color, and 



124 LECTURES IN DERMATOLOGY. 

made up of epithelial cells and sebaceous matter, con- 
taining in their centre a broken off, convoluted, or twisted 
hair. When the hairs are broken off each papule has a 
dark central point. The skin about the affected area is 
harsh, dry, and rough to the touch. When the hand is 
passed gently over the surface it feels like a nutmeg 
grater. It often has the appearance of " goose-flesh." 
The disease is usually not accompanied by any subjective 
symptoms, although there may be a little itching. The 
disease runs a chronic course, worse at times than others, 
and especially severe in cold weather. It lasts for years. 

Diagnosis. The diagnosis of this disease is seldom 
difficult, although it must be differentiated from cutis 
anserina, papular eczema, and papular syphilide. 

Treatment. The treatment of this affection is very un- 
satisfactory, and unfortunately you will frequently be 
called upon to treat it in young ladies who have it upon 
their arms, thus preventing them from wearing short- 
sleeved dresses. The same treatment which I have 
recommended to you in xeroderma or asteatosis, will in 
some cases give you a good result. After the use of the 
hot bath and friction with green soap, a lotion of one 
grain of bichloride of mercury to an ounce of cologne 
water is a very good application, and very agreeable to 
the patient ; but in any case do not promise your patients 
too much in the way of rapid improvement. 

LENTIGO. 

The most common skin disease with which you will 
meet is freckles or lentigo. In fact, it is so frequently 
met with that it is not often looked upon as a disease 
at all, but rather as a natural condition of the skin 
occurring under certain conditions. 



LENTIGO. 125 

Pathology. Lentigo is a disease of the pigmentary layer 
of the skin, and consists of the deposit of pigment in 
numerous small areas, otherwise the texture of the skin 
remains normal. 

Etiology. The direct cause of the disease is unknown, 
but we do know that exposure to the sun sets up some 
physical or chemical change in these pigmentary 
deposits to make them much more pronounced and of a 
darker color. 

Symptoms. Infants and elderly people are not subject 
to the disease. It occurs in children and young adults 
of both sexes with equal frequency. It occurs most fre- 
quently in persons of a fair complexion, and almost always 
in persons having red hair. The pigmentary deposits are 
about the size of a pin-head, often very numerous and 
placed closely together, but seldom confluent. The color 
varies from yellow to black, and the lesions are always 
more numerous and pronounced on those portions of the 
body exposed to the direct rays of the sun, as upon the 
backs of the hands, face, and neck, where they may give 
the skin a dirty appearance. Lentigo is unaccompanied 
with itching or other subjective symptoms. There is no 
disturbance of the general health. The lesions are always 
much worse in summer than in winter, sometimes almost 
entirely disappearing in cold weather. In many cases 
although apparently gone, if the skin is carefully exam- 
ined the pigmentary deposit may be seen, although of a 
much lighter color. Even if they do disappear for a sea- 
son they are almost sure to return again. 

Treatment. There is very little I can say to you as 
regards treatment. Any physician that can cure freckles 
will not need for further practice. Counter-irritation 
seems to have the most influence in removing these 



126 LECTURES IN DERMATOLOGY. 

blemishes. One patient whom I can recall had the dis- 
ease very badly, in fact it almost amounted to a disfigure- 
ment. The patient was entirely cured by an accident 
which resulted in a severe scorching of the face — a burn 
in the first degree. That was several years ago, and since 
then the patient has never been troubled with freckles 
on the face. I now treat all my freckled patients by 
severe counter-irritation of the skin with more or less 
benefit. This irritation may be produced by several 
methods, but the tincture of green soap rubbed in with a 
little bit of green flannel until the skin is reddened, is a 
favorite remedy with me. This can be applied every 
third, fourth, or fifth day, depending upon the amount 
of reaction set up in the skin. Bichloride of mercury 
seems to have some power of hastening the absorption of 
these pigmentary deposits, but it must be used in as 
strong solution as the patient can stand. You should 
advise your patients to bathe the face in hot water ten 
or fifteen minutes a day, and then apply the following 
solution : 

JJ Corrosive sublimate gr. vii 

Distilled water § vi 

Spirits camphor | ss 

Rose water 3 v 

m 

This treatment if continued for some time will give you 
the best results I can recommend ; but at best the treat- 
ment frequently fails, and you must not promise your 
patients to cure them of a trouble which although it in no 
way harms the general health or produces any unfavorable 
symptoms, yet they will certainly pay you well to get 
rid of. 



LEUCODERMA. 12 J 

LEUCODERMA. 

Pathology. Vitiligo or leucoderma is closely associated 
with chloasma, often occurring with it. The process con- 
sists in atrophy or absorption of the normal pigment of 
the skin in patches, and an hypertrophy or deposit of this 
pigment about the edges of these atrophic spots. 

Etiology. The disease is undoubtedly due to some 
nerve disturbance or innervation. As the general health 
does not suffer, the disease does not seem due to any ab- 
normal conditions affecting the body in general. 

Symptoms. The affection begins with the formation of 
several roundish or oval spots, which are white in color 
and surrounded by normal skin darker in color, the line 
of demarcation being well formed. These spots differ in 
size, but seldom get larger than the palm of the hand. 
New ones may continue to form, and uniting with the 
older ones produce large and irregular patches of whitish 
skin. These patches may appear upon any portion of the 
body, but are more apt to appear upon the trunk and 
backs of the hands. Hairs occurring in these spots usually 
turn white, but the glands, nerves, blood-vessels, and other 
skin structure, remain normal. There are no subjective 
sensations present, and the secretions are all right. The 
disease runs a chronic course. The spots gradually in- 
crease in size and number. The color seldom returns when 
once absent. 

Diagnosis. Leucoderma may be mistaken for lepra, 
tinea versicolor, chloasma, and pigmentary syphilide, but 
the diagnosis is not always difficult if you do not mistake 
the white color of the patches for the normal color of the 
skin. 

Treatment. The only success in treatment seems to 
lie in stimulating the patches. This may be done by 



128 LECTURES IN DERMATOLOGY. 

keeping up constant irritation by frequent applications of 
tincture of iodine, or by occasionally painting over the 
patches with acetic acid, or pure carbolic acid, or collodion, 
or cantharides, or by the application of irritating or blister- 
ing plasters, or other modes of treatment which usually 
result in pigmentation of the skin, and thus cure the af- 
fection. Another way of treating these cases, is by remov- 
ing the pigmentary deposit found around the edges of 
the patches by treatment recommended in my lecture on 
chloasma. You may stain the white patches with walnut 
juice and thus artificially obtain the natural color of the 
skin, if your patient is very anxious to have something 
done, no matter if only temporarily. The internal 
administration of nerve tonics and bromides is recom- 
mended, but I doubt if you will derive any good result 
from their use so far as the condition of the skin is con- 
cerned. 

LICHEN PLANUS. 

Lichen planus has until recently been regarded as one 
variety of that very rare disease lichen ruber, but late in- 
vestigation, especially by Taylor, has established without 
doubt that this disease is distinctly different in patho- 
logical symptoms and course from lichen ruber, and 
therefore should not be described or classified with it. 
Lichen planus is a chronic, inflammatory disease of the 
skin seen quite frequently in this country. 

Etiology. Its cause is unknown, but it is seen most 
frequently in persons of a rheumatic diathesis. It attacks 
adults rather than children, and is more common in men 
than women. 

Symptoms. The lesions characteristic of lichen planus 



LICHLN PLANUS. 1 29 

are papules, varying in size from a pinhead to a split pea. 
They are peculiar in shape, being angular, quadrangular 
or polygonal. They are often placed so closely together 
as to form patches or lesions, but when examined under the 
lens they are found seldom to lose their individuality, and 
around the edges of the patches the lesions are always 
discrete. The papules rise abruptly above the skin, but 
are flattened on their surface, and may present an umbili- 
cation. They are very firm to the touch, and slightly 
scaly. The color of the papules is very peculiar, they 
having a distinctly silvery, violaceous hue. When the 
lesions unite to form patches or ridges they seem to 
follow the natural lines of the skin or nerve trunks. 
Itching is usually severe. The lesions may appear upon 
any portion of the body, but are especially apt to 
attack the flexor surface of the forearm, wrists and 
ankles, and are almost symmetrical. The disease lasts 
for months or years, but eventually gets well, leaving 
pigmentation which lasts for a long time. Relapses are 
not very common. 

Diagnosis. The diagnosis of lichen planus is not always 
easy. It is very often mistaken for either psoriasis or 
papulo-squamous eczema. It must always be distinguished 
from lichen ruber and papulo-squamous syphilide, which it 
quite often resembles. 

Treatment. Treatment is not very satisfactory. The 
internal use of alkaline diuretics and the external use of 
ointments containing camphor in large quantities seems 
to act well in cutting short the disease and lessening the 
itching. Mud baths have in some few cases been followed 
by rapid and brilliant results. You can promise your 
patient a cure, but do not attempt to tell him when, or 
both you and your patient will be disappointed. 



1 30 LECTURES IN DERMA TOLOG Y. 

LICHEN TROPICUS. 

Under the more general term miliaria are often de- 
scribed two diseases of the skin, lichen tropicus and 
sudamina. 

Pathology. Lichen tropicus or " prickly heat " is an in- 
flammatory disease affecting the sweat glands. Conges- 
tion first takes place about the ducts of the glands, which 
is soon followed by a serous exudation resulting in the 
formation of papules or vesicles, usually of both. These 
lesions have their seat about the orifices of the excretory 
ducts. 

Etiology. The disease is almost always the result of 
heat, either caused by hot woollen clothing or high ex- 
ternal temperature; it is also frequently the result of 
feverish conditions. It is more common in hot tropical 
countries, and in summer than winter. Fat people and 
those who perspire freely are more subject to the disease. 
Young infants and children are especially liable to suffer 
from it, on account of the superfluous amount of under- 
clothing and woollen bands which they are so often bur- 
dened with by over-anxious mothers. 

Symptoms. Miliaria papulosa or lichen tropicus, or still 
more commonly known as prickly heat, usually com- 
mences as small, pin-head-sized accumulated papules, of 
a bright red color. They remain discrete, although ap- 
pearing in great numbers and placed very closely to- 
gether, often covering a large area. Between the papules 
a few vesicles often make their appearence. When 
present in large numbers they are usually very small, 
situated on an inflamed skin, and frequently described as 
miliaria rubra. The eruption is often preceded by sweat- 
ing, and accompanied by considerable itching and burning. 
It often develops within a few hours, but disappears less 



LICHEN TROPICUS. 131 

rapidly. It may occur upon any portion of the body, but 
is especially prone to attack the trunk. Relapses are 
common, and may be brought on by hot drinks or stimu- 
lating food. 

Diagnosis. This disease is most often mistaken for 
papular eczema, to which it has a close resemblance. It 
must also be diagnosed from scabies and eruptions of 
the skin the result of internal administration of medicines, 
as antipyrin. 

Treatment. As the principal cause of the disease is 
sweating, our first effort should be in controlling this 
activity of the sweat glands. A cool apartment and light 
clothing should be insisted upon. The patient should be 
fed on a light diet, avoiding all stimulating food, as meat, 
and hot or alcoholic drinks. The use of refrigerant 
drinks, such as the acetat and citrate of potash, should be 
given in lemonade, especially when occurring in infants 
and invalids. Aromatic sulphuric acid with some tonic 
is often serviceable. Atropine may be given in some 
cases to control the sweating. For local use mild dusting 
powders such as starch and lycopodium with a little 
salicylic acid added are very beneficial. Alkaline baths 
are also very agreeable and beneficial, taken once or twice 
a day. Lotions of sulphate of zinc or copper, or acetat 
of lead ten grains to the ounce, are frequently used in 
tropical countries for the relief of this affection. The 
following lotion I have used with great benefit : 

5, Zinci sulph., 
Acid, carbol., 

Alumin aa gr. viii 

Aq |ii 

m 



LECTURE IX. 

LUPUS ERYTHEMATOSUS, LUPUS VULGARIS, MILIUM 
AND MOLLUSCUM CONTAGIOSUM. 

LUPUS ERYTHEMATOSUS. 

Gentlemen : 

It is both unfortunate and confusing that we have two 
distinct diseases of the skin called lupus, one lupus ery- 
thematosus and the other lupus vulgaris. It is to the 
former that I now wish to call your attention. 

Pathology. In which layer of the skin the disease first 
begins is a little doubtful, but it probably has its primary 
seat about the sebaceous glands and follicles. After a 
while all the structures and layers of the skin become af- 
fected. There is a cell infiltration of the connective tissue, 
and a cell proliferation in the glands, giving rise to sebor- 
rhcea. If these conditions last for some time a degenera- 
tive metamorphosis takes place, resulting in absorption and 
atrophy of the skin and glands, perhaps resulting in the 
formation of cicatricial tissue. 

Etiology. Females are more subject to the disease than 
males, and especially those having a tendency to functional 
derangement of the sebaceous glands ; so indirectly those 
causes having a tendency to produce the latter disease 
may be considered a cause for the former. The immediate 
causes for the disease are, however, very obscure. 

Symptoms. The disease first shows itself by the 
presence of a few, small, pin-head-sized erythemic spots, 
which are usually found clustered together, and running 
132 



LUPUS ERYTHEMATOSUS. I 33 

into each other, forming one or more isolated patches. 
These patches, which are rounded or circumscribed, en- 
large very slowly by the extension of the disease from the 
centre towards the periphery, or by uniting with other 
patches, there often being several of such patches placed 
closely together. When two or more of these lesions have 
united, the patches become irregular in shape. The 
patches have a distinct and marginate outline separating 
them from the normal skin. Soon after forming, the 
lesions become covered with fine grayish or yellowish 
scales which are firmly adherent, but are not so abundant 
as to mask the color of the patches, which are distinctly 
violaceous in shade. Occasionally, however, they appear 
in the form of crusts, which completely cover the lesions, 
giving the appearance of a seborrhoea of the face. The 
scales or crusts are firmly attached to the openings 
of the sebaceous glands, sending a root-like pro- 
cess down into the ducts, which are distended and 
patulous. After the disease has lasted for a long time the 
central portions undergo atrophic changes, usually becom- 
ing paler in color and slightly depressed. Ulceration may 
take place with the formation of cicatricial tissue. Cica- 
tricial tissue may be, and often is, produced in the patches 
without ulceration first taking place. The seat of the 
disease is almost always about the face, affecting the 
cheeks and nose. As these regions are often invaded at 
the same time, a symmetry is produced which is likened 
to a bat with outspread wings. The scalp and ears are 
quite frequently attacked, but the rest of the body but 
seldom. The disease occasionally appears about the 
ankles and wrists. The subjective symptoms are not 
very marked. At times burning, itching, and pain are 
marked symptoms. 



134 LECTURES IN DERMATOLOGY. 

Course. The disease is very chronic, lasting usually 
through life, without especially interfering with the general 
health. After the patches have reached a certain size 
there are periods, sometimes of years, in which they do 
not grow at all, but they may at any time take on a patho- 
logical action and grow rapidly. 

Diagnosis. Great care must be taken in not confusing 
lupus erythematosus with lupus vulgaris, which it oc- 
casionally resembles. It is also apt to be mistaken for 
eczema, seborrhcea — especially the so-called eczema sebor- 
rhceicum affecting the face, — psoriasis, rosacea, syphilis, 
and ringworm or favus of the scalp. 

Treatment. The internal remedies which seem to be 
of use in the treatment of this affection are iodide of 
potash, iodide of starch, cod-liver oil, and arsenic ; but it is 
the exception to find any beneficial result from the use of 
internal remedies alone. For external application sapo- 
viridis, carbolic acid, and diachylon ointment containing 
salicylic acid are the three remedies which yield the best 
result. If the disease is of recent origin the use of green 
soap applied in the form of a plaster or rubbed into the 
skin in the form of tincture of green soap may effect a 
cure without other applications. If the disease is of long 
standing more heroic measures must be adopted. Paint- 
ing over the lesions every few days with pure carbolic 
acid has for many years been a favorite method of treat- 
ment, and given good results. During the past few years 
I have used the following solution with even better re- 
sults : 

1£ Acid, carbolic. 
Chloral, hyd., 
Tinct. iodi aa 3 ii 

m 



LUPUS VULGARIS. 1 35 

After this treatment has been applied for a few times 
the lesions may be treated with diachylon ointment, or 
better with diachylon plaster containing from 5 to 10 per 
cent, of salicylic acid. If these superficial caustics do not 
cure, resort may be had to linear scarification, making a 
.series of " cross hatchings," not going very deeply yet 
deep enough to cause considerable bleeding, which may 
be checked by pressure over a saturated solution of car- 
bolic acid dressing. 

Electrolysis by means of multiple punctures and scarifi- 
cation have occasionally given very brilliant results. Do 
not resort to actual cautery or strong escharotics unless 
necessary, for you will have more scarring than the disease 
is apt to produce if left alone. Occasionally, however, 
you will meet with a case which from its severity and 
obstinacy to other plans of treatment will require such 
bold treatment. 

LUPUS VULGARIS. 

Having told you something of lupus erythematosus, I 
will briefly speak of the other variety of lupus, called 
lupus vulgaris. 

Pathology. It has only been in the past few years that 
the nature of this form of lupus has been at all understood. 
It is a true tubercular inflammation of the skin, and caused 
by or associated with the tubercle bacilli. The inflamma- 
tory process seems to start in the corium, but eventually 
attacks the whole thickness of the skin. After a time 
retrograde metamorphosis sets in, causing a destruction 
of the newly formed tissue, leaving ulcerations in the skin 
which heal by cicatrization. Part of the lupus tissue, 
however, does not die, but undergoes permanent organi- 
zation with the production of new connective tissue, thus 



136 LECTURES IN DERMATOLOGY. 

causing hypertrophy of the skin. The epithelial and 
mucous layers sometimes become hypertrophied. The 
glandular appendages and follicles of the skin are fre- 
quently destroyed. 

Etiology. The disease seems especially apt to attack 
children, and particularly those of strumous diathesis. It 
does occur in persons of otherwise apparently perfect 
health. It is perhaps hereditary in some cases, but in all 
cases due to the presence of tubercle bacilli. The disease 
may be produced by inoculation. The reasons why the 
tubercular inflammation should attack the skin rather than 
other tissues of the body are obscure. 

Symptoms. Lupus vulgaris occurs most frequently 
about the face, but may appear upon any portion of the 
body, especially about the hands and feet. It usually 
begins as a number of small, round, reddish or yellowish 
points, situated beneath the skin. These points increase in 
size, resulting in the formation of papules and tubercles. 
They coalesce, forming a patch which is circumscribed, 
pronounced in outline, and dull red in color. The tuber- 
cles are usually firm in consistence, but so very soft that 
a probe can be thrust deeply into them with a very little 
effort. These nodules may undergo absorption, leaving 
an atrophy of the skin, but they may ulcerate, causing 
destruction of it. The patches grow from the centre 
towards the periphery by the addition of new tubercles, 
but have very little tendency to heal at the centre, al- 
though ulceration may go on at that point resulting in 
the formation of scar tissue. 

There are usually not more than one or two lupus 
patches present at one time, and these patches are usually 
not very extensive in area. When ulceration in these 
patches takes place, crusts form which are usually easily 



LUPUS VULGARIS. 1 37 

removed, leaving unhealthy, exuberant granulations be- 
neath. Cicatrization does, however, usually take place, 
but the scar being of low vitality becomes the seat of the 
disease, and again ulceration may occur. At times the 
ulceration is so deep as to cause destruction of the tissues 
beneath the skin, resulting in great deformity, as the loss 
of the nose or ears. These deep ulcerations may event- 
ually heal, but leave frightful scars. Occasionally when 
the disease attacks the nose or ears it causes them to 
shrink up to half their size, due to absorption of the tissue 
and not to ulceration. 

There is one form of lupus vulgaris in which the individu- 
al lesions show no tendency to group or to form patches. 
This variety is called disseminated lupus. It occurs 
upon the face, and often is mistaken for acne. The 
destructive process is not very great, the tubercles 
terminating in small ulcerations or atrophied spots. 
This form of the disease is seen most frequently in young 
adults. 

Diagnosis. It is not always easy to diagnose lupus vul- 
garis correctly. There are two diseases especially which 
look very much like it, viz., tubercular syphilide and epi- 
thelioma. The disease must also be diagnosed from 
leprosy, erythematous lupus, and rosacea. 

Treatment. There are three things to be aimed at in 
the treatment of local tuberculosis or lupus. First, the 
removal of the morbid tissue ; secondly, that this removal 
be accompanied with as little pain as possible ; and thirdly, 
that the treatment should result in the least disfigurement. 
There are several plans of treatment, some of which are 
decidedly preferable to others. 

In the first place there is the removal of the tissue by 
excision. If the disease is limited in extent this can be 



I38 LECTURES IN DERMATOLOGY. 

•done thoroughly, and with very good result. If, however, 
it covers large areas, this plan of treatment should never 
be adopted. 

In the second place there is the cautery. This is a plan 
of treatment which is not now very much used. It is 
always painful, and is not accompanied by any specially 
brilliant results. 

Linear scarification by means of the actual cautery has 
been employed in certain cases with good results. 

The curette is an instrument well deserving a high 
reputation in the treatment of lupus. The curette in the 
form of a Volkmann spoon can hardly be improved. It 
removes all of the lupus tissue with little pain, and com- 
paratively little disfigurement. It has the advantage of 
removing only the diseased tissue and not, if a little care 
be exercised, any of the surrounding healthy skin. 

The dental burr, or dental excavator, can be used in 
certain cases with great advantage. When lupus appears 
in the form of disseminating nodules the dental burr will 
be found greatly superior to the curette. This little in- 
strument when thrust into the lupus nodule and screwed 
about removes all the lupus tissue without causing any 
deformity, and without producing much pain. It is, how- 
ever, far inferior to the curette, except in those cases 
where the nodules are disseminated. 

Scarification has frequently been employed in the treat- 
ment of lupus, and is now used very largely by all derma- 
tologists. This scarification is done by the linear method. 
A large number of parallel lines are cut through the lupus 
tissue very close together, this seeming later to destroy 
the lupus growth, permitting a new growth of connective 
tissue to take place, which tends to preserve the size and 
form of all the important features attacked. The lupus 



LUPUS VULGARIS. 1 39 

cells seem by this method of treatment to greatly alter 
their configuration, and to assume the shape of fibres of 
connective tissue, in this way preserving the size and 
shape of the organs attacked, especially when the disease 
occurs about the nose. 

Caustics of various kinds are frequently employed in the 
treatment of lupus. Among them may be mentioned 
nitrate of silver, caustic potash, chloride of zinc, and 
ethylate of sodium. They possess no special value in the 
treatment of lupus, and are accordingly inferior to other 
methods of treatment. 

The application of pyrogallol, however, to lupus, after 
its surface has been thoroughly curetted, with a view to 
the complete destruction of the lupus tissue, has met with 
great favor. This is perhaps the best method of treat- 
ment, and may be carried out as follows : The lupus patch 
is first thoroughly curetted. A ten-per-cent. ointment of 
pyrogallol is then thoroughly applied twice daily for three 
or five days, when the surface appears swollen and of a 
dirty grayish hue. Iodoform is then plentifully applied 
to check the pain produced by the ointment. This is 
then covered with linen smeared with boric acid ointment, 
and bandaged for several weeks until the suppuration 
lessens and healing begins. Mercurial plaster is then 
applied, and the wound usually heals kindly. If any of 
the lupus tissue still remains, the same treatment is re- 
peated until the disease is entirely cured. 

Of recent years Unna has applied to lupus surfaces a 
strong ointment consisting of two parts of beech tar creo- 
sote and one part of salicylic acid. Before this ointment 
is applied, the epithelial covering of the lupus is first de- 
stroyed, either by scarification or by the curette. The 
pain produced by this ointment is very severe until the 



140 LECTURES IN DERMATOLOGY. 

creosote has acted as an anaesthetic, so that it is first wise 
to apply a solution of cocaine, which deadens the pain 
until the secondary effects of the creosote will control it. 
This remedy leaves a smooth cicatrix, but according to 
Unna redness of the scar is apt to remain for some time, 
owing to a paralysis of the capillary blood-vessels. 

A one-per-cent. alcoholic solution of fuchsine has re- 
cently been employed painted over the lupus patch after 
it has first been superficially scarified. This may be done 
twice a week until the lupus is cured. It has one advan- 
tage, of being almost entirely painless. 

Koch's treatment by the injection of lymph has not 
been followed with the success which we all hoped for. 
The remedy does seem to possess some peculiar influence 
on the lupus patch. Its injection is always followed by 
a reaction, the patch becomes reddened, inflamed, and 
sometimes followed by suppuration. In a few cases the 
tubercles have flattened, and a decided improvement has 
been noticed. A cure, however, never results, and an 
improvement only in a certain number of cases. We 
must therefore depend almost entirely upon the local de- 
struction of the patch in one way or another. The one 
which I most highly recommend to you is the scarifica- 
tion followed by the use of the pyrogallol, and afterwards 
by the mercury plaster. 

While the local treatment is being carried on, internal 
or constitutional treatment should not be neglected. 
The patient should be placed in the best hygienic sur- 
roundings, and have the best of food and nourishment 
in the way of malt liquors, and should have the in- 
ternal treatment of iron, preferably the iodide of iron 
and the iodide of starch in as large quantities as can be 
borne. 



MOLL USC UM CONTAGIOSUM. 141 

MILIUM. 

A very frequent disease of the skin, but one which you 
will not frequently be called upon to treat, as it does not 
often attract the attention of the patient, is milium. 

Pathology. The disease is due to the retained secretion 
of the sebaceous glands, caused by the upper layer of the 
corium growing over their opening ducts. The secretion 
not being able to escape, dries or becomes calcareous, and 
produces the following symptoms : 

Symptoms. The lesions are usually most numerous 
about the eyes, scrotum, penis or labia. When they occur 
in the eyelids they are called chalazions. They make 
their appearance as small, hard, white or yellowish raised 
papules, oblong or rounded in shape, and without subjec- 
tive symptoms. They are very firm to the touch, some- 
times almost stony in hardness, feeling like a foreign body 
in the skin. There may be only one or two of them, or 
they may occur in scores. They remain indefinitely, but 
sometimes disappear without treatment either by absorp- 
tion, or by the contents of the glands gradually reaching 
the surface of the epithelium and being thrown off. Milia 
usually occur with comedones, and must be diagnosed 
from them. 

Treatmeitt. The treatment is very simple. You may 
remove the lesions by electrolysis, or better still, scoop 
out the contents of the gland with a dermal spear and 
touch the cavity with a stick of nitrate of silver or car- 
bolic acid, thus destroying the gland and preventing the 
secretion from again accumulating. 

MOLLUSCUM CONTAGIOSUM. 

Pathology. Molluscum contagiosum is a disease whose 
pathology is not at all well understood. In later micro- 



142 LECTURES IN DERMATOLOGY. 

scopical researches there has been found in the lesions the 
presence of little bodies called psorosperms, supposedly a 
vegetable parasite, which is now considered the cause of 
the disease ; but as these little bodies are also found pres- 
ent in other pathological conditions, as epithelial cancer, 
pityriasis rubra pilaris, etc., it is very doubtful if these 
bodies have anything to do with the cause of the disease. 
The older observers believed that the seat of the disease 
was in the sebaceous glands, but this is probably a mis- 
take, as all recent investigators hold that the process 
begins in the mucous layer of the epidermis. When the 
disease reaches its full development, and one of the little 
tumors is excised, the contents may be expressed as 
cheesy, fluid-like mass. On section these tumors pre- 
sent the appearance of a lobulated gland, the interior 
being soft and capable of being pressed out, while the 
wall corresponds to the Malpighian layer of skin, gradu- 
ally hypertrophied. The soft matter consists of altered 
or degenerated epithelial cells and psorosperms. Virchow 
considered the disease as beginning in the hair follicles. 

Etiology. The disease is undoubtedly contagious, and 
conveyed from one person to another. It seldom occurs 
in adults, but in children who for the most part are neg- 
lected and ill-fed. As it sometimes makes its appearance 
without any possible chance of infection, it is possible 
that it may develop from causes of which we know 
nothing. 

Symptoms. The lesions usually make their appearance 
upon the face, hands, or penis, but may occur upon any 
portion of the body. They may occur singly, but are 
usually seen in numbers and in various stages of develop- 
ment. When first noticed they are usually about the size 
of a pin-head, white in color, with a waxy appearance. 
They gradually increase in size until they are as large and 



MOLLUSCUM C0NTAG1OSUM. 145 

about the shape of a split-pea. They usually retain their 
waxy appearance, but may become pinkish. Upon their 
summits they are flattened and often depressed, present- 
ing a dark point of opening, through which a sebaceous 
material may be squeezed in a thread-like form. These 
little tumors are firm to the touch and are not painful. 
All inflammatory symptoms are usually absent, and the 
patient seldom complains of any subjective symptoms. 
The lesions last for a variable length of time, but usually 
weeks or months, terminating eventually by disintegration 
and sloughing. 

Diagnosis. Molluscum contagiosum when occurring on 
the genitals is quite frequently diagnosed as a venereal 
disease. Be careful not to make this awkward mistake. 
Also do not confuse them, when seen on other portions of 
the body, with simple warts, milia, or small-pox vesico- 
pustules. 

Treatment. As the disease is purely a local one it may 
be cured by external means alone. If the lesions are 
small and of moderate size they are best treated by 
thrusting the sharp point of a probe dipped in pure 
carbolic acid deeply into the mass through the opening 
in the summit, and then applying white precipitate oint- 
ment or mercurial plaster. This method may have to be 
repeated once or twice to ensure a complete cure. When 
the lesions are quite large they may be excised with the 
dermal curette, and their bases touched with the nitrate 
of silver. A common way of treating these tumors is by 
making an incision across their tops, squeezing out their 
contents, and cauterizing the interior with pure carbolic 
acid or nitrate of silver. Be careful that your treatment 
is not too heroic, for you may leave a scar which would 
not result if you had allowed the case to end in spontane- 
ous recovery. 



LECTURE X. 

■NjEVI, PEDICULOSIS, PEMPHIGUS, PITYRIASIS ROSEA, 
AND PRURITUS. 

NiEVUS PIGMENTOSUS. 

Gentlemen : 

There are several kinds of naevi or moles to which I 
would ask your attention, and the first of them is the 
naevus pigmentosus. 

Description. Pigmentary naevi may consist only of cir- 
cumscribed deposits of pigment in the skin without any 
other change, or there may be in addition an hypertrophy 
of all its structures. They vary much in size, from a 
split-pea to a silver dollar ; in shape from round or oval 
to irregular patches, and in color from a yellow to a black. 
Some are flat, others decidedly elevated above the skin. 
The surface may be soft and smooth (nsevus spilus), or 
rough, furrowed, and watery (naevus verrucosus). Some- 
times they consist of soft, fatty connective-tissue growths 
called naevus lipomatodes. Many exhibit a bountiful 
growth of hair, and are called naevus pilosus. Naevi 
may be either congenital or acquired. The hairy naevi 
always belong to the former variety. They occur upon 
any portion of the body, but especially upon the face, 
neck, and back. Naevi grow to a certain size and after- 
ward remain inactive unless irritated, when they may 
become malignant. 

Treatment. Moles, unless disfiguring or showing 
M4 



CAPILLARY NMVUS. 145 

a tendency to become malignant, as the warty variety 
sometimes does, require no treatment unless the patient 
insists upon getting rid of the lesions. They may be re- 
moved by the knife with a small, plastic operation, or they 
may be destroyed with caustics. If caustics such as nitric 
acid or potassi are used they should be applied thoroughly, 
for frequent irritation of the naevus may result in convert- 
ing it into a malignant growth. For a hairy naevus elec- 
trolysis gives the best result, and for other naevi the 
application of ethylate of sodium. This should be ap- 
plied with a glass rod, care being taken not to get the 
solution on the normal skin. A crust will form, which 
becomes detached in about three weeks, leaving a slight 
scar. If the mole is large, only a portion of it should be 
treated at one time. 

CAPILLARY N^VUS. 

Another variety of naevi is the capillary naevus, also 
known as birth-mark, strawberry stain, mother s mark, 
port-wine stain, teleangiectasis, etc. 

Pathology. Capillary naevus consists of a circumscribed 
and permanent dilatation of the capillary blood-vessels of 
the skin, often with pigmentary deposits. The surface is 
usually smooth, but may be furrowed, warty, and covered 
with hair. The patches are usually irregular in shape and 
vary greatly in size. 

Etiology. They are congenital, and undoubtedly often 
the result of maternal impressions upon the foetus in 
utero. 

Treatment. The various modes of treatment recom- 
mended in the pigmentary naevi are beneficial in this 
variety of the disease. When the lesions are large but a 
small area should be treated at one time. Multiple scari- 



146 LECTURES IN DERMATOLOGY. 

fication of port-wine stain is employed with a view to 
dividing the small cutaneous blood-vessels, and thus les- 
sening the blood supply to the diseased area. This is 
best done by making a number of parallel incisions 
through the skin very close together, about one sixteenth 
of an inch apart. After these are healed a second set 
running obliquely to the first set are made, and so on 
until the whole area of the disease has been gone over. 
The skin can first be frozen with rigoline or ether spray, 
and then the incisions made with the multiple scarificator 
without pain. 

Another method of treatment which is superior to 
scarification is electrolysis by multiple puncture. The 
negative pole is to be connected with the needle holder, 
and the operation conducted as I explained to you in re- 
moving superfluous hairs. A needle-holder containing 
several needles set in a row or in a circle may be used in- 
stead of a single needle, although there is more danger 
of producing a scar. The punctures must be about one 
sixteenth of an inch apart. Multiple puncture may also 
be performed by first dipping the needle into nitrate of 
mercury or fuming nitric acid ; but in large capillary naevi 
electrolysis is undoubtedly the best plan of treatment. 
Small naevi may be cured by applications of caustics, 
especially nitric acid. 

PEDICULOSIS. 

You will be called upon so frequently to treat skin 
diseases resulting from the presence of lice upon some 
portion of the body, that I cannot pass by the subject of 
pediculosis without saying a few words. There are three 
kinds of lice which live upon the human skin. First those 
which attack the scalp, called pediculosis capites ; second, 



PEDICULOSIS CAPITIS. 147 

those which attack the body, called pediculosis corporis; 
and third, those which make their appearance about the 
pubis and axilla and are known as pediculosis pubis or crab 
lice. They are splendid breeders, the young hatching out in 
seven days, and capable in eighteen days of propagating 
their species. A female louse may become the grand- 
mother of five thousand lice in eight weeks. 

PEDICULOSIS CAPITIS. 

Head lice first attack the occipital region, and although 
they may afterwards appear on other portions of the 
scalp, especially the parietal regions, it is here we find 
the most serious lesions. 

These lesions consist of a dermatitis very much like a 
pustular eczema, from which it is very difficult to diag- 
nose. The hair becomes matted together by a sticky 
secretion, often bloody and offensive, while the scalp is 
cedematous and covered with pustules, blood crusts, and 
scabs. These lesions are mostly the result of scratch- 
ing, caused by the irritation of the lice moving about and 
sucking the blood, although you must remember that they 
do not bite as a flea does, for instance. 

Diagnosis. Be careful not to mistake the lesions result- 
ing, from the presence of lice with pustular eczema, im- 
petigo contagiosa, or seborrhcea of the scalp. The 
presence of the lice themselves or their nits will always 
aid you in making the correct diagnosis. 

Treatment. Head lice can best be cured by saturating 
the head with petroleum, or with tincture of delphinium 
or larkspur, leaving it on overnight, and washing off with 
soap and water in the morning. Two or three applications 
of this will usually be sufficient. After thus getting rid 
of the cause you can treat the resulting dermatitis. The 



I48 LECTURES IN DERMATOLOGY. 

following ointment you will find very beneficial, applied 
once or twice a day : 

B Ung. hyd. ammon., 

Ung. zinc, ox aa § ss 

01. rusci 3 i 

m 

It is only occasionally that you will be obliged to cut off 
the hair to cure the disease. 

PEDICULOSIS CORPORIS. 

There is probably no disease of the skin which causes 
so much suffering from itching as that resulting from 
the body louse. The little animal attacks any portion of 
the body or extremities, but directs its worst attacks on 
the back and shoulders. Its crawling over the skin and 
piercing it with its haustellum for feeding purposes pro- 
duces the most frightful desire to scratch, so much so that 
patients almost always tear the skin in trying to get relief, 
and from this irritation most of the skin lesions are pro- 
duced. These lesions consist of scratch marks usually 
parallel, minute blood crusts, and sometimes papules and 
pustules. An eczematous dermatitis may be set up in 
places if the irritation is long continued. 

Diagnosis. Pediculosis corporis must be diagnosed from 
papular eczema, prurigo, scabies, and pruritus. The pres- 
ence of the parasite or its nits, with the long parallel 
scratch marks, will greatly aid you in forming a correct 
opinion. 

Treatment. As the parasite does not live on the body 
but on the clothing, you can always cure the disease by 
removing the cause and the clothing at the same time. 
Never tell a patient that he is lousy unless you are able 



PEDICULOSIS PUBIS. 149 

to back up your opinion quite forcibly. You had much 
better tell him that a change of under-clothing every day 
is very necessary to properly cure the disease. I know 
of nothing better than a strong solution of carbolic acid 
rubbed over the body two or three times a day to relieve 
the itching, and to prevent the lice from biting. 

PEDICULOSIS PUBIS. 

Pediculosis pubis or crab lice although usually affecting 
the pubic region, may attach themselves to the hairs or 
any portion of the body, and we very often find them in 
the axilla or eyelashes. Itching, excoriations, and eczema- 
tous lesions are the symptoms present, and although they 
are not so severe as in the other forms of pediculosis 
which I have given you, they are often more rebellious 
to treatment. 

Diagnosis. The diagnosis is not difficult. You are not 
liable to mistake this disease for any other, unless it is 
eczema or pruritus. 

Treatment. The following ointment will cure the dis- 
ease. It may be applied at night, and washed off in 
the morning. Two or three applications are usually 
sufficient : 

^ Acid carbolici gr. x 

Bals. peru 3 ss 

Ung. hyd. nit., 

Sulphur sub aa 3 i 

Petrolat ad | i 

m 

PEMPHIGUS. 
There are several diseases of the skin usually described 
under the term pemphigus, but there is one variety quite 



150 LECTURES IN DERMATOLOGY. 

commonly met with, which simply consists in the 
production of blebs. 

Pathology. A hyperemia of the skin may or may not 
precede an exudation which is poured out from the capil- 
laries of the papillary layer, lifting up the epidermis in 
the form of blebs. This exudation is usually serum, but 
may contain pus cells and occasionally blood. 

Etiology. The causes producing pemphigus are very 
obscure. It occurs more frequently in children than 
adults, and usually with those having bad hygienic sur- 
roundings and who are poorly nourished. It may accom- 
pany severe menstrual disorder and pregnancy. 

Symptoms. As I told you, there are several distinct 
varieties of pemphigus, but most of them are so very rare 
that I will simply call your attention to the only one you 
will probably ever see in general practice. This common 
variety is pemphigus vulgaris. 

The disease, although it may occur on any portion of 
the body, is more apt to attack the extremities, especially 
the lower extremities and the soles of the feet. The first 
symptom may be a little irritation of the skin where the 
lesions are to form, but usually the first thing noticed is 
the appearance of the blebs. They appear in groups of 
six, eight, and ten at a time, and upon a slightly reddened 
surface. They usually develop rapidly, reaching their full 
size — that of a walnut — within twenty-four hours, each 
bleb running its course in from three to six days without 
rupturing, drying up and falling off in the form of scales, 
leaving a reddened surface beneath. 

These blebs are round or oval in shape, rise abruptly 
from the normal skin, and are not surrounded by an in- 
flammatory areola. Their walls are thin and fully dis- 
tended with clear serum, yellowish in color, becoming 



PEMPHIGUS. I5I 

cloudy after a day or two. Sometimes the serum is 
stained with blood. They show no tendency to group, 
but appear in crops, one crop no sooner disappearing than 
another begins. The disease may run an acute course 
and be associated with acute constitutional symptoms, as 
fever. This is quite common in children, the disease 
lasting but two or three weeks ; but in adults it is almost 
always chronic, and not accompanied with constitutional 
symptoms. 

Diagnosis. Pemphigus is most apt to be mistaken for 
erythema multiforme, the so-called erythema bullosum, 
for hydroa and bullous urticaria. Occasionally in children 
the bullae of impetigo contagiosa may look like those of 
pemphigus. 

Treatment. As the disease is often associated with 
much debility, iron and tonics with cod-liver oil are 
usually required. For internal treatment directed tow- 
ard the cure of the lesions, we have almost a specific in 
arsenic. This is one skin disease in which arsenic has a 
decided and rapid action. It may be given in the form 
of Fowler's solution, and in as large doses as the patient 
can bear. 

For external treatment, the blebs should be opened as 
soon as formed, and the excoriated surface treated with 
some bland, antiseptic, and soothing ointment which is 
drying, such as the following : 

5 Acid, boric gr. xv 

Amyli, 

Zinc. ox. aa 3 ii 

Ung. aq. rosae § i 

m 

Oxide of zinc ointment, or equal parts of this and diachy- 
lon ointment, are also of service after dusting- the lesions 



152 LECTURES IN DERMATOLOGY. 

with aristol. Hebra has recommended for severe cases, 
where the disease continues after other means have failed, 
that the patient be kept in a continuous bath, the water 
kept at about the temperature of the body and changed 
every day or oftener. The patient is to be kept in this 
bath for weeks or months, eating and sleeping there. 
Some cases even then do badly. The general health fails, 
they have repeated febrile attacks, and eventually die 
from the disease or become so weakened that they die 
from some recurrent attack. The disease is more serious 
in adults than in children. 

PITYRIASIS ROSEA. 

Pityriasis rosea or pityriasis maculata et circinata is not 
a common disease, or one which you will often see, and, 
if it was not so frequently mistaken for ringworm or vice 
versa, I should not take up your time in describing it 
to you. Although rare, the disease is undoubtedly more 
frequently met with than reported, it being diagnosed as 
simple ringworm. 

Symptoms. An outbreak of pityriasis rosea is often pre- 
ceded by some slight constitutional symptoms, as head- 
ache or general malaise, but not always. The eruption is 
almost always confined to the neck, shoulders, chest, and 
back. When first noticed, it consists of small red papules 
surrounded by some redness, but soon enlarges into ele- 
vated, rosy-red macules, with a well defined border. In 
a few days they reach their full development, of from half 
to one inch in diameter, and begin to fade in the centre. 
The centre of each lesion turns a yellowish color, looking 
like parchment, and becomes scaly, while the border re- 
mains elevated and retains its red color. Later, only 
rings may remain, which are round unless two or more of 



PRURITUS. 153 

the lesions unite, when the borders are irregular. New- 
lesions form from time to time, while others disappear, 
so that we find them in all stages of development. The 
lesions are quite numerous, each individual one lasting 
for a week or more. There are very few subjective symp- 
toms, slight itching being usually present. The disease 
ends in spontaneous recovery in about two months. 

Etiology. The cause of the disease is unknown, but it 
is probably parasitic in nature, only slightly contagious. 

Diagnosis. The disease is almost always diagnosed 
ringworm by those not acquainted with it. It is also 
mistaken for seborrhcea sicca, annular urticaria, psoriasis, 
and syphilis. 

Treatment. The disease tends towards spontaneous 
recovery, but I think you can hasten a cure by applying 
once or twice a day the following lotion : 

^ Pot. sulphuret 3 i 

Aq |" 

Solve et adde solutionem subquentem. 

Zinc, sulph 3 i 

Aq. rosae § ii 

m 

PRURITUS. 

Pruritus is a functional, cutaneous affection manifesting 
itself solely by the presence of the sensation of itching 
without structural alteration of the skin. I wish you to 
remember that speaking of this disease I do not mean 
any of the numerous skin diseases in which you all know 
itching is simply a symptom accompanying the lesions. 
In this disease itching is the disease in itself, and is never 
associated with any primary lesions. Lesions may form 
secondarily, but if they do it is always the result of the 



154 LECTURES IN DERMATOLOGY. 

scratching and never the cause of it. The intensity of 
the itching varies in different cases. In some cases it is 
so slight that it produces rather an agreeable sensation 
than otherwise, and it is a pleasure to the patient to 
scratch or have the skin rubbed. An example of this is 
the tendency which children have to wish their backs 
rubbed at night before retiring. In other cases the itch- 
ing is so severe that patients frequently prefer a pain to 
the intense itching. A pain in many of these cases is 
produced by the patient to take the place of that terrible 
sensation which is produced by the intolerable and 
continuous itching. 

Etiology. There are no lesions present which will 
account for the causes producing itching. It is supposed 
to be in many cases due to a cutaneous hyperplasia or 
excessive irritability of the cutaneous nerves. This con- 
dition results from a general neurotic condition, or is due 
to local changes in the skin. In some cases it is due to 
impaired conduction in the cutaneous nerves to the nerve 
centres. This has been termed hypo-pselaphesia. Among 
the exciting causes may be mentioned reflex irritation, 
the result of some disease or derangement of the inter- 
nal organs or nerve centres, or may result from external 
causes setting up irritation or structural change in the 
skin. Occasionally itching results from the ingestion of 
some obnoxious materials which are distributed to the 
skin by the blood, setting up an irritation of the cuta- 
neous nerves, resulting in the sensation of itching. 
Jaundice produces itching from some such cause, the 
bile pigment being deposited in the skin. 

Symptoms. The only direct symptom detected with 
pruritus is the irresistible desire to scratch and rub the 
skin. This may be associated with nerve symptoms, or 



PRURITUS. 155 

secondarily by local skin lesions, the result of continued 
scratching, which generally expresses itself in roughened, 
hyperaemic and excoriated conditions of the skin. The 
itching is usually intermittent, and almost always worse 
at night. The sensation rarely invades the whole body 
at one time, though various regions may in turn be 
attacked. In most cases it occurs in certain localities, 
chiefly the scalp, genitals, and anus. Scratching relieves 
itching by one of two ways, either by substituting for 
the pruritus painful or voluptuous sensations, or by active 
irritation of the skin by counter-irritation, producing 
better conductivity in the nerves, thus removing the 
cause of the itching. 

Diagnosis. The neurosis pruritus must not be confused 
with other diseases of the skin that have itching for a 
symptom. You must also remember that the irritation 
of the skin by constant scratching will produce lesions 
which are not the cause but the result of the disease. 
Pruritus must therefore be diagnosed from prurigo, 
papular eczema, scabies, pediculosis, etc. 

Treatment. Treatment of pruritus must depend very 
largely upo-n the cause. In many cases where this cannot 
be determined, the internal use of salicylate of soda in 10- 
grain doses three or four times a day is followed by very 
beneficial results. In other cases the following prescrip- 
tion seems to be very satisfactory : 

IJ Antipyrini gr v 

Pot. brom gr x 

Aq. lauro-cerasi 3 i 

m 

Again in other cases you will find better results by 
ordering the following pill taken at bedtime, and if 
necessary once or twice during the day : 



156 LECTURES IN DERMATOLOGY. 

5, Gelsemin gr -^ 

Ext. cannabis ind gr \ 

Fiat. pil. no. 1 

m 

If the digestive functions are deranged, attention to the 
diet will usually be followed by some relief. When there 
is some local irritation of the skin which results in itching, 
the treatment of the affection will usually result in a cure. 
For the immediate relief of itching local applications are 
numerous. The one which, however, has the best, and a 
more lasting effect, than any other is very hot applications 
of carbolic acid from 2 to 5 per cent. Tar in some cases, 
in the form of a tar ointment, is beneficial. When itching 
is about the mucous surfaces, the application of ointments 
containing cocaine relieve it for the time being ; but these 
remedies are all superficial in their result, relieving the 
symptoms but not curing the disease. Change of air and 
of hygienic surroundings will do more for the majority of 
these cases than any external or internal treatment. As 
the disease occurs more frequently in old people than in 
the young, general attention to the kidneys is always 
advisable, for not infrequently it occurs in those who have 
Bright's disease, or in those suffering from diabetes. At 
best you will have great trouble in curing your patient, 
for patients troubled with this affection travel from one 
physician to another, from one place to another, seeking 
aid from an affection which in itself is not dangerous, 
yet produces terrible results on account of the wakeful- 
ness and irritation to the nerves this disease produces. 
The danger of your patients resorting to the use of 
narcotics, especially morphine for relief at night, is very 
great, and you will do well to keep this in mind, for the 
opium habit can in this way be very easily contracted. 



LECTURE XL 

PSORIASIS, PURPURA. 

PSORIASIS. 

Gentlemen : 

To-day I will ask your attention to a very common, 
dry, scaly skin disease called psoriasis or dry tetter. 

Pathology. Psoriasis is a distinctly inflammatory disease 
of the skin, affecting the deeper layers of the epidermis. 
It begins as a hyperaemia, which results in an hyperplasia 
of the rete mucosa. The papillary layer, although seem- 
ingly thickened, is not much affected unless the disease 
has lasted for a long time. In the later stages of the 
disease the blood-vessels of the corium become dilated, 
and the corium itself infiltrated with cellular elements and 
serum, which, however, are entirely absorbed as the 
trouble disappears. The glandular elements of the skin 
are not affected, but there is a hyperplasia of the hair-root 
sheaths. As the disease is a superficial one, without 
many structural changes in the skin, after death the 
lesions are not very apparent to the naked eye, but seem 
like superficial collections of scales. 

Etiology. The disease never occurs in infants, and is 
seldom seen in children under ten years of age. It occurs 
in both sexes with equal frequency, and in both the well 
and the poorly nourished. It is more frequently seen in 
cold than in hot weather. A predisposition to it may be 
i57 



158 LECTURES IN DERMATOLOGY. 

inherited, but in the majority of cases it cannot be said to 
be traced to either parent. Some dermatologists insist 
that psoriasis is always the result of some syphilitic taint, 
but this cannot be proven in the vast majority of cases, 
and probably has nothing to do with syphilis. Ingestion 
of certain articles of food and drink may precipitate an 
attack or aggravate it, but never seems to be the original 
cause. Psoriasis occurs more frequently in those who 
suffer from a gouty or rheumatic tendency, but the true 
causes of the disease have never been determined. 

Symptoms. Psoriasis always begins as small, red, 
slightly elevated spots, which immediately become cov- 
ered with white scales. These spots gradually increase 
in size until, in a few weeks, they may form large 
patches. As these patches assume different features as to 
size and shape, they are designated accordingly by special 
names. Thus, when the spots remain pin-head size, the 
disease is called psoriasis punctata; when they remain the 
size of drops, psoriasis guttata is the name given; when 
the spots remain the size of coins, the term psoriasis mum- 
ularis is given, which is a very common form ; when the 
spots clear up in the centre and continue to spread at the 
periphery, the disease is known as psoriasis circinata, or, 
if they unite with other similar lesions, thus forming 
broken segments of circles or festoons, it is called psori- 
asis gyrata ; when the patches are very large and irregular 
in shape, either the result of individual development or 
the union of several lesions, thus covering a considerable 
area, the term psoriasis diffusa is employed. The scales 
of psoriasis covering the patches, although superficial, are 
strongly adherent, requiring some force to remove them, 
and then leaving bleeding spots. They are usually very 
abundant, and of mother-of-pearl whiteness. The patches 



PSORIASIS. 159 

themselves, when freed of scales, are usually of a bright 
red color, with a sharp line of demarcation separating 
them from the normal skin. The patches are usually not 
very much elevated above the skin, although they often 
seem to be very much so when covered with scales. The 
red color of the patches may also be almost entirely lost 
by the abundance of white scales upon their surface. The 
thickness of the patches varies very much. In most cases, 
when the disease has not lasted very long, after the scales 
are removed it will be found quite slight, and there is never 
as much thickening as the general appearance of the patch 
would indicate, as the lesions, you will remember, are 
mostly in the superficial layers of the skin and confined 
to them in the earlier stages. The disease may occur 
upon any portion of the body, but the extensor surfaces 
of the extremities are most apt to be affected. The back 
is more apt to be involved than the chest, and the scalp 
than the face. When it attacks the scalp, the disease 
usually extends slightly beyond the edges of the hair. 
When you suspect a case of psoriasis, always examine the 
elbows and knees, for these are points where the lesions 
are especially apt to appear. The number of patches 
found upon the body at one time varies greatly, but the 
smaller the size of the lesions, the greater their number, 
as a rule. There is but little tendency toward symmetry 
of the lesions, except when it attacks the palms or soles. 
The one subjective symptom which accompanies the 
lesion is itching, which is usually well pronounced. Burn- 
ing is sometimes present, but only when the lesions take 
on an acute inflammatory action, as they sometimes do as 
a result of irritation, etc. 

Diagnosis. A differential diagnosis must be made be- 
tween psoriasis and squamous and seborrhceal eczema* 



l6o LECTURES IN DERMATOLOGY. 

squamous syphilide, lichen planus, seborrhcea, especially 
of the scalp, pityriasis rosea, tinea tonsurans, and ery- 
thematous lupus. It is not always easy to diagnose 
psoriasis from these affections, but if you will carefully 
remember the group of symptoms I have just given, you 
will not often make a mistake. 

Treatment. The treatment of psoriasis is both internal 
and external. Arsenic, mercury, and the alkalies are the 
internal remedies in which we can place the most reliance. 
In the early stages of the disease, the alkalies, either given 
alone or combined with small doses of Fowler's solution 
of arsenic is usually followed by a good result. In the 
later stages larger doses of arsenic, or, better still, arsenic 
and mercury combined, as in Donovan's solution, is often 
curative without any external treatment at all. This bene- 
ficial action of mercury is claimed by many to be a proof 
of the syphilitic origin of the disease, but as this is often 
the only reason for considering it in any way related to 
syphilis, it does not seem to me to warrant such an opin- 
ion. We know of the beneficial action of mercury in 
diphtheria, undoubtedly curative in some cases, and yet 
no one for a minute would consider syphilis related to, or 
the cause of, diphtheria. Carbolic acid stands next to 
arsenic as an efficacious remedy, and should be given in 
two- or three-grain doses after meals, well diluted. Phos- 
phorus and tar are also favorite drugs with many for the 
cure of psoriasis. Whatever drug is used for its cure, you 
must remember that the disease disappears slowly, and 
that your remedies must be given for some time after all 
traces of the lesions have disappeared. Diet does not 
seem to influence the disease very much, but malt liquors 
have a tendency to increase the number of the lesions and 
to retard recovery, and should therefore be prohibited. 



PSORIASIS. l6l 

The same may be said of sweet wines. Animal food, 
fruit, and green vegetables are the best articles of diet for 
persons suffering from psoriasis. Persons drinking large 
quantities of alkaline waters seem to derive benefit by 
hastening the disappearance of the disease. 

Local Treatment. There are two drugs which you will 
find of more benefit in the local treatment of psoriasis 
than all the others put together. These are tar and chry- 
sarobin. You must use these drugs judiciously, however, 
if you wish a good result. Not all cases should be 
treated by these applications. For instance, when the 
disease is very extensive and of the punctate or guttate 
variety, chrysarobin should not be used, and the patients 
may often do better without the use of tar, depending 
entirely in these cases upon internal medication and the 
use of alkaline baths, with tar and sulphur soaps. In all 
cases, before any application is made, the scales must first 
be removed. This may be done by continuous applica- 
tions to the lesions for several hours of a 5 % salicyliated 
oil, and then giving an alkaline bath. If the lesions are 
not very extensive and are not situated upon the face and 
hands, chrysarobin without any doubt will give the best 
uniform results. It may be used either in a 5 or 10 % 
ointment or paint. The latter is neater and easier to use, 
but may not be as well borne by the skin, especially in 
the earlier stages of the disease. There are several ob- 
jections to the use of chrysarobin which you must always 
bear in mind. In the first place, if applied to the 
normal skin it will frequently set up a very acute derma- 
titis, which about the face is almost erysipelatous. It 
contains a dye-stuff which stains the skin, nails, and hair 
badly, also the clothing of the patient. If applied over 
a large area of skin constitutional symptoms may also 



l62 LECTURES IN DERMATOLOGY. 

manifest themselves, due to the absorption of the drug. 
For these reasons you must exercise some care and dis- 
cretion in using this drug, and never use it about the face 
or scalp, or apply it indiscriminately over the normal 
skir.. When you do use it, in either ointment or paint, 
apply it only to the diseased surface. In chronic cases 
with much thickening, the chrysarobin paint is a very 
elegant way of using this remedy. It may also be used 
with advantage when the lesions are small and numerous, 
for you can limit the extent of surface to which it is to be 
applied much better than you could with an ointment. 
A little salicylic acid added to the chrysarobin seems to 
increase its efficacy by softening the epithelma, removing 
the scales, and increasing its penetrating action. The 
paint may be made as follows: 

ty Acid, salicylic 3 ss 

Acid, chrysophanic 3i 

Liq. gutta percha § i 

A paint of this kind should be applied to the lesions 
every second or third day, carefully removing all the 
loose scales from the patches before the paint is re-applied. 
Chrysarobin should never be used if acute inflammatory 
symptoms are present in the psoriatic patches, as are 
occasionally seen. Should the disease have lasted for a 
short time or should it be very extensive, or should for 
any reason chrysarobin not be well borne we should resort 
to the use of one of the tarry preparations. An ointment 
which I have found very serviceable, especially in psoriasis 
of the scalp, consists of the following : 

5, Ol. rusci 3 i 

Ung. hyd. ammon, 

Lanolin aa f ss 

m 



PSORIASIS. 163 

In place of the oil of rusci, cade may be used in the 
strength of one or two drachms to the ounce. With these 
tarry preparations hot alkaline baths with the use of tar 
soap should be taken frequently. Tar is disagreeable to 
use, first, on account of its odor, and, secondly, if used very 
extensively and in strong preparations enough may be 
absorbed to cause some constitutional symptoms, as 
headache and fever. An application frequently made to 
psoriasis with good results is pyrogallic acid in ointment, 
half a drachm to the ounce. It acts very much like chry- 
sarobin, but more slowly and not so well. It is, however, 
free from injurious effects. Occasionally you will find 
old patches of psoriasis with much thickening that will 
not yield to the treatment just suggested. In these cases 
I advise painting over the patch every third or fourth 
day with equal parts of tincture of iodine, chloral, and 
carbolic acid, and if the reaction is not too great, keep con- 
stantly applied between such applications the following 
ointment : 

5, Ung. picis 3 ii 

Ung. ac. carb 3 ii 

Ung. diachylon ad 3 i 

These chronic lesions disappear often quite rapidly 
under this plan of treatment. It requires patience to 
successfully treat psoriasis, but if you will carry out some 
such plan as I have just suggested to you, I am sure you 
will not be disappointed with the result. Remember 
that when an inflammatory action is set up by your 
vigorous treatment, stop all irritating applications and 
use some soothing ointment until the inflammation has 
subsided. 



1 64 LECTURES IN DERMATOLOGY. 

PURPURA. 

Hemorrhages in the skin are named, from their form and 
size, petechiae, vibices, and ecchymoses. 

Petechia are small, round, or irregular-shaped hemor- 
rhagic spots. 

Vibices are long, narrow, streak-like hemorrhages in the 
skin. 

Ecchymoses are large, irregular, flat, and superficial 
patches of extravasated blood. 

Not all hemorrhagic affections of the skin are the result 
of extravasation, but are most frequently due to diape- 
desis of the red blood corpuscles or their coloring matter. 
When cutaneous hemorrhages are the result of injury 
they are called idiopathic, but when due to constitutional 
causes they are called symptomatic, and it is only to the 
latter I wish to direct your attention. Cutaneous hemor- 
rhages are common in certain constitutional diseases, as 
small-pox and typhus fever, and also as a secondary 
symptom of some skin diseases, as pemphigus and 
ecthyma ; but I wish now to call your attention to certain 
skin diseases which have hemorrhages into the skin as a 
primary and principal factor, and which occur independent 
of other cutaneous lesions. Such skin diseases are called 
purpura. 

There are three varieties of purpuric skin diseases, 
namely, purpura simplex ; purpura rheumatica, and purpura 
hemorrhagica. 

Pathology. The pathology of these three diseases of 
the skin is the same as far as the lesions go. The ex- 
travasation or diapedesis usually takes place rapidly. It 
may have its seat in the deeper layers of the corium, or 
about the glands and follicles. The size of the lesions and 
their shape depend entirely upon the permeability of the 



PURPURA SIMPLEX. 1 65 

tissues and the amount of exudation or extravasation. 
Occasionally the blood is poured out through the sweat 
glands, and escapes through the sweat ducts upon the 
surface of the skin, producing hematidrosis or bloody 
sweat. Usually blood, once out of the vessels, remains in 
the tissues of the skin and must be absorbed before it 
disappears. This is generally a slow process, as the color- 
ing matter undergoes several changes, turning in the pro- 
cess of absorption from a red color to yellow, green, blue, 
and purple. 

Diagnosis. The diagnosis of purpura is seldom difficult. 
You must distinguish each variety from the others, and 
also from flea-bites, erythema multiforme, and scurvy. 
The only form of purpura which you will be liable to 
confound with scurvy is the purpura hemorrhagica, which 
is often called land scurvy owing to its similarity to the 
true disease. 

PURPURA SIMPLEX. 

Etiology. The causes of purpura simplex are very ob- 
scure, and differ somewhat according to the variety of the 
disease. Although it does occur in the well nourished it 
is more apt to attack debilitated subjects, and to occur 
more frequently in the old than in the young. Malaria is 
considered a frequent cause. 

Symptoms. Usually the disease begins suddenly with- 
out any constitutional symptoms, although it may be 
preceded by some general malaise, or not infrequently by 
some oedema of the extremities. The lesions may all 
make their appearance within twenty-four hours, or they 
may develop more gradually. They are about the size 
of a pin-head or larger, and at first of a bright red color, 
which will not disappear upon pressure. They usually ap- 
pear in large numbers upon the lower extremities, although 



l66 LECTURES IN DERMATOLOGY. 

other portions of the body may be attacked, and are dis- 
crete, having little or no tendency to form in groups. 
Usually subjective symptoms are absent, but if present 
the skin is usually very irritable, so that scratching may 
be followed by the formation of welts and wheals. 

Course. The individual lesions usually last two or three 
weeks, but as new crops then make their appearance the 
disease may last for months. Occasionally you will find 
the lesions very rapidly absorbed — in two or three days 
they may entirely disappear. 

Treatment. The internal administration of ergot and 
iron are the two drugs upon which you can place a good 
deal of reliance. The fluid extract of ergot and tincture 
of the chloride of iron are the two preparations which 
should be used. If the disease is produced by malaria, 
quinine and mineral acids are required. Rest in bed for 
the first few days seems important. Absorption of the 
blood may be hastened by hot baths and fomentations 
after the exudation has stopped, and by bandaging. 

PURPURA RHEUMATICA. 

Etiology. Rheumatism, or rheumatica diathesis, is 
always the cause of this variety of purpura. 

Symptoms. The lesions always follow an attack of 
articular rheumatism, usually an acute attack, but not 
always. Usually cutaneous lesions make their appear- 
ance after the rheumatic symptoms have lasted a week or 
more, and may attack any portion of the body, but most 
frequently the extremities. These lesions are scattered, 
rounded or irregular in shape, of a dark red or bluish color, 
and vary in size from a split pea to a finger nail. There 
is often considerable anaemia and depression present while 
the eruption lasts, but the rheumatic symptoms are 



PURPURA HEMORRHAGICA. \6j 

generally somewhat relieved. With the exception of 
some soreness in the skin there are no subjective 
symptoms present. The disease occurs more often in 
women than in men, and usually young adults. The 
lesions usually last for two or three weeks, gradually disap- 
pearing, but new crops may form from time to time if the 
rheumatic tendency continues. 

Treatment. The treatment consists in giving drugs for 
the cure of the rheumatism as well as for the external 
lesions. For the latter the same treatment as suggested 
for purpura simplex may be employed. Cod-liver oil and 
tonics are especially indicated. Iodide of potash is es- 
pecially serviceable, not only for the rheumatic symptoms, 
but to hasten the absorption of the purpuric spots. A 
change of climate and occupation are advisable to prevent 
return of the trouble. 

PURPURA HEMORRHAGICA. 

Etiology. The cause of purpura hemorrhagica, or land 
scurvy, is always the result of general debility or nerve 
exhaustion, causing the loss of tone in the vasomotor 
centres. 

Symptoms. The skin lesions play only a secondary 
part in this variety of purpura. They are always pre- 
ceded by debility, loss of appetite, general malaise, and 
anaemia. The spots always first make their appearance 
on the lower extremities, gradually extending upward in- 
volving the trunk. They are large and irregular in size, 
often uniting, forming patches the size of the palm of the 
hand. With these cutaneous hemorrhages bleeding from 
the mucous surface, as the nose, gums, mouth, bowels, 
etc., takes place, accompanied by a great loss of vitality, 
sometimes ending fatally. It occurs in both children and 



l68 LECTURES IN DERMATOLOGY. 

adults, but most frequently in females. There are slight 
or no subjective symptoms accompanying the skin lesion. 
Treatment. There is little to be said in the way of 
treatment except to employ those agencies recommended 
for the internal treatment of purpura simplex. The 
patient must remain in bed, and be given a nutritious 
diet of easily digested food and drink. Inhalations of 
oxygen seem to be beneficial in some cases. Hemor- 
rhages of the mucous surface must be treated according 
to their locality and the condition of the patient. The 
following prescription is very serviceable as a mouth 
wash in case of bleeding from the gums: 

3 Tine, ratanhiae ... 3H 

Tine, iodine 3i 

Aquae ad § ii 

Remember the disease is always a serious one, and liable 
to end fatally. 



LECTURE XII. 

ROSACEA, SCABIES, SEBORRHEA, SUDAAIINA, AND 
SYCOSIS. 

Gentlemen : 

Rosacea is a disease in many respects resembling acne, 
and for that reason frequently called acne rosacea. 

Pathology. There are three stages to acne rosacea, 
the pathology differing somewhat in each stage. In 
the first stage there is simply an increase of blood in the 
skin, the result of capillary and venous stasis. In the 
second stage this stasis produces a prominent dilatation 
and hypertrophy of the walls of the blood-vessels, and 
the sebaceous glands become affected as in acne. In the 
third stage there is an hypertrophy of all the tissues of the 
skin, accompanied by a new growth of connective tissue 
and perhaps lipomatous growths, often producing a great 
deal of deformity. 

Etiology. This disease is more common in men than 
in women, but when occurring in the latter it is usually 
present at the climacteric period, and seems to result from 
menstrual disorder, but seldom passes beyond the second 
stage. Disorders of the digestive and generative organs 
seem to be a frequent cause of the disease. Constant 
use of alcoholic liquids, owing probably to their tendency 
to upset the digestion, and also to their physiological 
property of dilating the superficial blood-vessels, is the 
169 



I 70 LECTURES IN DERMA TOLGG Y. 

most common cause of acne rosacea, hence the term 
given to this disease, as " brandy nose " or " whiskey- 
nose," is not misapplied. Cabmen and others who are con- 
stantly exposed to all kinds of weather and changes of 
temperature often suffer from this disease, but are more 
liable to it if they are intemperate. Not infrequently no 
cause can be assigned for the trouble. Persons who 
suffer from seborrhcea seem especially susceptible. 

Symptoms. The disease may first show itself by a 
seborrhcea of the face and nose. At other times it be- 
gins as a passive congestion of the blood-vessels, as shown 
by a profuse redness of these parts, which feel cold rather 
than warm to the touch. After several weeks or months 
the second stage sets in. The redness is more prominent, 
and upon close examination the cutaneous blood-vessels 
are seen to be large and dilated, running a tortuous and 
irregular course. Acne papules and pustules manifest 
themselves, coming and going, but rarely absent. Active 
inflammation is present at times, associated with much 
heat and redness. The disease usually begins about the 
nose, and spreads gradually on either side and above, 
until both cheeks and forehead are attacked. Occasion- 
ally it begins on the forehead. After lasting in the 
second stage for a variable length of time, sometimes 
never advancing beyond this, the symptoms of the third 
stage appear. The changes usually begin in the nose, 
and often are limited to it. This organ becomes greatly 
enlarged, either keeping its normal shape or contorted 
into irregular shapes, being more or less lobulated and 
pendulous. This enlargement is due to hypertrophy of 
the sebaceous glands and the tissue about them. 

Course. The disease is a very chronic one. In the 
first stage it seems to improve for a time, and then gets 



ROSACEA. 171 

worse again. In the second stage it often seems worse 
at times, due to the acute attacks of acne which are 
present, causing an active inflammation. In the third 
stage it remains about the same all the time, but gradually 
getting worse. 

Diagnosis. Rosacea is a disease usually quite easily 
diagnosed, but sometimes very apt to be mistaken for 
other skin symptoms. Perhaps it is most often confounded 
with a tubercular syphilide, which very often attacks the 
face and nose. It may also be mistaken for lupus vul- 
garis and lupus erythematous, which, you will remember, 
I told you most frequently occurred about the face and 
nose. In the first stages of the disease you must be care- 
ful not to mistake it for an erythematous eczema. 

Treatment. The treatment of the first and second 
stages is frequently attended with good results, but in 
that of the third stage we can only hope for some im- 
provement. The causes producing the disease should be 
sought for, and remedied if possible. The patient should 
be put on a plain diet, and all alcoholic liquors forbidden. 
Sugars also seem to be harmful. A more generous diet, 
with tonics and cod-liver oil, is required in those cases 
occurring in the young and anaemic. The mineral acids 
and nux vomica are almost always beneficial. As to the 
internal remedies used for their direct influence upon the 
skin lesion, ergot stands at the head. It is useful in all 
stages, with good results, and should be given in large 
doses after meals. In the second stage, where the acne 
symptoms are prominent, the sulphide of calcium, given 
in small doses frequently repeated, is very beneficial. 

For local treatment the continued and prolonged use 
of hot water is very serviceable in all stages, especially 
the second. After each application of the hot water a 



172 LECTURES IN DERMATOLOGY. 

lotion of bichloride of mercury, I grain, and resorcin, 15 
grains to the ounce, may be applied with benefit. In 
other cases sulphur seems to act to much better advan- 
tage. Early in the disease, or in mild attacks, the follow- 
ing lotion may be used with advantage : 

Pot sulphuret 3 i 

Aq |ii 

Solve et adde solutionem subquentem, 

Zinc, sulph 3 i 

Aq. rosae § ii 

m 

In later stages, or in more severe forms of the disease, 
the following lotion is to be preferred : 

Gum. tragacanth gr v 

Camphor grx 

Sulphur, sub 3 iss 

Aq. calcis ad 3 ii 

A 5- to 10-per-cent. solution of ichthyol has been used re- 
cently both externally and internally by Unna with good 
results in this disease. During the acute inflammatory 
attacks of the second stage a soothing ointment must be 
used, such as Lassar's paste. Much can be accomplished 
surgically for this disease to hasten the removal of pus- 
tules, and to destroy dilated vessels and hypertrophied 
tissue. The pustules are best removed by puncturing 
them with the dermal spear, and turning it around in the 
lesions to destroy their walls, or by use of the dermal 
curette. When the blood-vessels are permanently dilated. 



SCABIES. 173 

scarification yields the best result by obliterating the ves- 
sels, thus lessening the redness and limiting the patho- 
logical process going on in the tissues of the skin. These 
vessels may be obliterated by electrolysis, but scarification 
is better. In the third stage, surgical treatment is about 
the only one that will be attended with any kind of a 
result. 

SCABIES. 

We now come to the consideration of another form of 
animal parasite which attacks the skin, producing a dis- 
ease called scabies, or more commonly the itch. 

Pathology. The little insects which produce all the 
lesions and symptoms of this disease are called the sarcop- 
tes scabiei, and are just visible to the naked eye. They 
are both male and female, and the female, as usual, causes 
all the trouble. The adult female has a convex back 
with several rows of sharp spines protruding from it. She 
has eight legs, four anteriorly and four posteriorly, and is 
armed with curved bristles. The male is only about half 
the size of the female, but his organs of generation 
are well developed. The young of either sex are recog- 
nized by having two hind legs. The female burrows 
through the horny layer of the epidermis to deposit her 
eggs in the skin, and after laying about a dozen eggs in 
a row, at the rate of two eggs a day, she dies, having 
faithfully performed her mission in life. These eggs 
hatch out in about eight days. The young burrow deeply 
into the skin until they are matured, and then come to 
the surface, where the female becomes impregnated, and 
burrows again into the skin to lay her eggs, while the 
male remains on the surface of the skin or is pushed off. 
The life of the animal is about three months, not longer 
— but long enough. 



174 LECTURES IN DERMATOLOGY. 

Etiology. The disease arises from contagion, and from 
that only. It occurs among all classes, and at all ages. 
It is very contagious, and may be communicated by 
merely shaking hands. It is most apt to occur among 
the uncleanly and in crowded quarters. 

Symptoms. The first symptom which usually attracts 
the attention of the person who has contracted the 
disease is itching. Upon examination on the place of 
irritation will be found a few punctate spots, pustules, or 
vesicles. These lesions usually first appear about the 
hands and between the fingers, but spread rapidly, until 
at the end of three weeks or more the disease becomes 
general. A few days after the disease first makes its 
appearance in the form of puncta, papules, or vesicles, new 
lesions form which consist of burrows, excoriations, blood 
crusts, pustules, and crusts, seated on a more or less red- 
dened skin. The longer the disease has lasted the greater 
will be the number and variety of cutaneous lesions. These 
burrows are due to the raising up of the epidermis by the 
itch mite, as a mole will raise the earth as it burrows into 
the ground. They are usually about one quarter of an 
inch in length, and irregular, yellowish in color, and end 
abruptly in dark points. The primary lesion, namely, 
the papules, vesicles, and pustules, are all the result of 
the irritation produced by the mite in the skin, while the 
secondary lesions come from the scratching of the patient, 
and result in the form of scratch marks, blood crusts, 
excoriations, and crusts. Lastly, if the disease has lasted 
for some time a general dermatitis is set up, as is shown 
by the reddening, infiltration, and pigmentation of the 
skin about the lesions, where the disease is most active. 
Itching is usually very severe, especially at night. 

Seat of disease. The regions of the body attacked are 



SCABIES. 175, 

characteristic. Between the fingers, wrists, axilla, mam- 
mae, especially about the nipple, and penis, are the por- 
tions of the body almost invariably attacked, although all 
portions of the body may become affected. 

Course. The disease is sometimes called seven years' 
itch on account of the length of time it lasts if not treated. 
It will, however, in time, without treatment, undergo a 
spontaneous cure, but will last for months or years. 
Relapses are quite common from auto-infection, the 
disease not being completely cured. You will remember 
that I told you the length of life of each itch mite is 
about three months, so do not tell your patient that he is 
positively cured until he has passed this stage of proba- 
tion. 

Diagnosis. There is probably no disease of the skin so 
easily diagnosed, yet so frequently diagnosed wrongly as 
scabies. A differential diagnosis must always be made 
between scabies and prurigo, papular eczema, pediculosis, 
miliaria, and impetigo-contagiosa. The microscope will 
always aid you in the right direction. 

Treatment. There are two drugs that I can recommend 
to you in the treatment of this disease, sulphur and balsam 
of Peru. They may be used alone or in combination. I 
usually have my patient to take a hot bath every night if 
possible, then rub into the skin wherever the disease pre- 
sents itself the following ointment : 

3, Bals. Peru 3 i 

Ung. sulph. alkal. ... % i 

After a few applications the treatment may be applied 
every second and then every third night, but continued 
for at least three weeks. This is usually all that is neces- 
sary. Flour of sulphur may be rubbed into the skin or 



176 LECTURES IN DERMATOLOGY. 

plain sulphur ointment used, but the alkaline sulphur 
ointment seems to be more penetrating and efficacious. 
Occasionally the sulphur will set up a dermatitis when its 
use will have to be discontinued for a few days, and 
Lassar's paste used in its place. When sulphur cannot 
be used at all, or is unsatisfactory, you may employ in the 
same way the following ointment : 

B /?— Naphthol .... 3ii 

Sapo. viridis .... 3 iii 

Pulv cretae alb 3 i 

Vaseline § i 

m 

Be sure to see that your patients are very careful to 
change their underclothing after each bath, and that it is 
thoroughly boiled and ironed before again using, for the 
parasite will live in it indefinitely and cause reinfection. 
SEBORRHCEA. 

Seborrhcea is usually a functional derangement of the 
sebaceous glands, although after the disease has lasted 
for a long time structural change may take place in the 
glands and hair follicles, as atrophy and alopecia. This 
functional disorder results in an altered and increased 
flow of secretion from the glands, which is either oily or 
firm in consistence. This secretion consists of sebum and 
cells, sometimes one and sometimes the other predomi- 
nating. 

Etiology. Many cases of the disease occur without any 
known cause, but it is much more apt to occur in persons 
suffering from some debilitating disease as struma or 
anaemia, or those having functional derangement of the 
digestive or generative organs. The same constitutional 
causes producing acne will often result in seborrhcea. 



SEBORRHCEA. IJJ 

Symptoms. Seborrhcea may begin on any portion of 
the body, but its most common seat is the scalp, and the 
next in frequency is the face. It also appears on the 
sternum and the scapulae. It is usually not accompanied 
with any signs of inflammation, and itching is the only 
subjective symptom present. There are three distinct 
varieties of the disease depending on the character of the 
glandular secretions, viz. : seborrhcea oleosa, seborrhcea 
sicca, and seborrhceal eczema. 

I. In the oily variety, called seborrhcea oleosa, the secre- 
tion is decidedly oily, and usually attacks the non-hairy 
portions of the body, and is especially apt to appear on 
the face and about the nose and forehead. The skin 
looks as if it had been smeared with dirty yellowish oil, 
which when wiped off on a handkerchief leaves a grease 
spot and soon forms again on the affected area. It is 
almost always accompanied with acne and comedones. 

II. Seborrhcea sicca is a more common form, and ap- 
pears on either the hairy or non-hairy portions of the 
body. It consists of dry or more or less greasy masses of 
scales or crusts of yellowish color, and having a tendency 
to adhere to the skin. 

Seborrhcea capitis is the most common example of this 
variety of the disease, and is the most frequent cause of 
premature baldness. It is usually distributed over the 
scalp in the form of small, dry scales, easily detached, 
and called dandruff. Less frequently there is formed 
crust-like, greasy masses, which adhere to the scalp and 
paste the hair down to it. Under these scales or crusts 
the scalp will usually be found of a dull grayish color, but 
in some cases, especially when crusts are found, more or 
less hyperaemia is present. The hair gradually becomes 
lustreless and dry, and falls out. In does not grow again, 



178 LECTURES IN DERMATOLOGY. 

as the hair follicles become atrophied. As the crown of 
the head is usually most seriously attacked, baldness be- 
gins in this area. When the process affects the bearded 
portion of the face, the scales are almost always dry, small, 
and easily detached. It occurs frequently about the chest. 
III. Seborrheal eczema. This third variety differs from 
the others in being accompanied by a varying amount of 
dermatitis, which is considered eczematous by some, and 
consequently called seborrhoeal eczema or eczema sebor- 
rhceicum. It occurs especially about the forehead and 
alse nasi, also on the scalp, chest, and back. It occurs 
most frequently in young adults, and is often accompanied 
by a distinctly inflammatory process. The affected skin 
is reddish and irritable, accompanied by burning and 
itching. The mouths of the sebaceous glands are patu- 
lous, secreting a thick, greasy material, which, drying on 
the surface in thick yellowish crusts, may form a mask to 
the part. When removed they will, in a few days, form 
again. This is especially common in infants, occurring on 
the scalp and perhaps extending over the face, and known 
as " milk crust." When eczema seborrhceicum occurs on 
the chest, over the sternum, or on the back, the eruption 
will often assume the form of circular patches covered 
with yellowish crusts, with the edges of a bright red color. 
These patches may run together, forming irregularly 
shaped patches with scalloped borders. The crusts may 
be removed with soap and water, or even by the irritation 
of the clothing, leaving circles or rings, slightly elevated 
and of a yellowish-red color. Although the skin in this 
variety of seborrhcea is red, it is not moist or infiltrated, 
as in ordinary eczema. Seborrhcea will run on indefi- 
nitely unless treated, and will often, when apparently 
cured, return after a time. 



SEBORRHEA. 1 79 

Diagnosis. It is sometimes quite difficult to diagnose 
seborrhoeal eczema from a true eczema. It is also fre- 
quently mistaken for pityriasis rosea, ringworm, and 
tinea versicolor. Seborrhcea occurring about the face or 
scalp, must be differentiated from erythematous lupus, 
psoriasis, ringworm of the scalp, and favus. 

Treatment. Tonics and cod-liver oil are usually indi- 
cated for internal treatment. Tar, carbolic acid, green 
soap, sulphur, and resorcin are the drugs which may be 
employed externally with great advantage in seborrhcea. 
For the treatment of dry seborrhcea of the scalp, I will 
refer you to my lecture on alopecia. When the crusts are 
greasy, alkaline sulphur ointment rubbed into the scalp 
at night will be found more efficacious than any other 
remedy. In seborrhcea of the face and elsewhere, sulphur 
and resorcin are the two remedies which give the best 
results. The sulphur ointment, one half strength, may be 
kept applied at night and washed off with hot water and 
tar soap in the morning, and then a fifteen-grain solution 
of resorcin to an ounce of rose water applied once or twice 
during the day. Seborrhcea oleosa affecting the nose is 
often greatly benefited by bathing the nose once or twice 
a day with sulphuric ether and then dusting with a powder 
composed of equal parts of sulphur and lycopodium. An 
ointment of 

B Hyd. ammon 3 ss 

Hyd. chlor. mit 3 iss 

Ung. aq. rosae § i 

m 

is better borne by both the skin and the scalp in some 
cases than is the sulphur. In eczema seborrhceicum you 
will find the following ointment very serviceable : 



180 LECTURES IN DERMATOLOGY. 

$ Resorcini gr. xx 

Ung. hyd. ammon., 

Vaseline aa § ss 

m 

SUDAMINA. 

Under the more general term miliaria are often described 
as two diseases of the skin, lichen tropicus and sudamina. 

Pathology. They are both inflammatory affections of 
the sweat glands. Congestion first takes place about the 
ducts of the glands, which is soon followed by a serous 
exudation, resulting in the formation of papules and vesi- 
cles, usually of both. These lesions have their seat about 
the orifices of the excretory ducts. 

Etiology. The disease is almost always the result of 
heat, either caused by hot woollen clothing or high ex- 
ternal temperature ; it is also frequently the result of 
feverish conditions. It is more common in hot tropical 
countries, and in summer, than in winter. Fat people 
and those who perspire freely are more subject to the 
disease. 

Miliaria vesiculosa or sudamina appears as small, pin- 
point-sized vesicles, which rise abruptly above the skin 
and often in great numbers. Thousands of them appear 
in one patch, but although placed very closely together 
they remain discrete, giving the skin a yellowish 
appearance. The skin from which they arise is usually of 
a bright-red color, owing to the fact that each vesicle is 
surrounded by a small areola. The eruption is preceded 
by considerable sweating, and accompanied by itching and 
burning. The trunk is usually the seat of the disease, 
but it often appears on the extremities. It may appear 
in patches, or generally diffused. The eruption often 



SYCOSIS. 181 

appears suddenly and lasts for a few days, the vesicles 
drying up or terminating in slight desquamation. If the 
vesicles are ruptured, as by scratching, slight crusting 
may result. Relapses are very common. This variety 
of disease is more frequently seen in children, or in 
patients suffering from feverish conditions. 

Diagnosis. Sudamina must be diagnosed from vesicu- 
lar eczema, to which it bears a close resemblance. It is 
not apt to be mistaken for any other disease. 

Treatment. In the general treatment of sudamina I 
will refer you to my lecture on lichen tropicus. A very 
good lotion, however, to use for frequent applications, is 
the following : 

5 Calaminae 

Zinc ox aa 3 ss 

Glycerini 3 ss ii 

Aq. calcis ad § ii 

m 

SYCOSIS. 

When we come to the study of the vegetable parasitic 
skin diseases, I will describe to you a parasitic sycosis or 
barber's itch. We have still another form of sycosis, 
called the sycosis non-parasitic, and one which is not 
caused by the ringworm, as in the other variety. To 
this variety I will now call your attention. 

Pathology. The disease begins as an inflammation 
about the hair follicles, and is therefore at first not a fol- 
liculitis, but the peri-folliculitis. As a result of this inflam- 
mation pus is formed. The inflammation soon extends 
to the follicles, softens and ruptures them, so that the pus 
may thus enter the follicles. The cells of the follicles 
and the hair roots undergo granular degeneration. The 



1 82 LECTURES IN DERMATOLOGY. 

pus may reach the surface of the skin by either rupturing 
into the hair follicles, or through the rete mucosum. 
Except in some severe cases, the hair follicles do not 
become completely destroyed, the hair remaining firmly 
implanted ; but in cases where they are destroyed the 
hairs become loose, and the follicle sheath accompanies 
the hair when extracted. In these severe cases, alopecia 
results from the severity of the disease. 

Etiology. The disease is not contagious, and its cause 
is very obscure. It is not produced by shaving, for it 
occurs often in those who do not shave. It is not a 
disease due to a debilitated condition, for it occurs in those 
who are in perfect health. It is probably a germ disease. 

Symptoms. Sycosis is a disease of the hairy portions of 
the face and neck. It may attack all of these parts at 
one time, but more frequently begins at one spot, 
gradually extending to other regions. It first shows it- 
self as papules, or more commonly as pustules, surround- 
ing the hairs. They are usually at first few in number, 
but appear in successive crops until they are very numerous 
and cover considerable space. These pustules are about 
pin-head size and pointed, containing a yellowish fluid, 
and showing little tendency to rupture. These pustules 
remain discrete, although often crowded together, and are 
surrounded by an inflammatory areola", giving the skin a 
swollen and reddened appearance. If the pustules are 
not ruptured in shaving they dry up into yellowish crusts, 
which fall off without leaving scars. Besides the pustules, 
papules and papulo-pustules are usually present, situated 
immediately about the hairs. The hairs are not usually 
deformed, and are not easily extracted, and then with 
pain. The disease is usually accompanied by more or 
less pain and burning, but little itching. 



SYCOSIS. 183 

Course. The disease is a chronic one. As some of the 
lesions disappear, new ones continue to form. This con- 
tinued inflammation of the skin leads to some chronic 
thickening, which may remain after the other lesions 
have disappeared. 

Diagnosis. Sycosis is most liable to be mistaken for 
barber's itch and for a pustulur eczema. It must, how- 
ever, also be differentiated from a pustular syphilide, lupus, 
and acne. 

Treatment. Internal treatment is not of much impor- 
tance. In cases which have lasted for a long time the 
internal use of Donovan's solution has a beneficial effect. 
In all cases, the bowels should be kept thoroughly active 
with the use of alkaline salts. If pustulation is very ex- 
tensive, sulphide of calcium in small and frequent doses 
may limit its amount. For local treatment you should 
advise your patients not to shave, but to keep the hairs 
closely clipped. If the disease is acute and accompanied 
by inflammatory symptoms, the soothing antiseptic oint- 
ment and lotions should be applied. The affected area 
should be bathed in hot water two or three times a day, 
and a calomel lotion applied. 

3 Hyd. chlor. mit gr xv. 

Liq. calcis 3 ii 

m 

At night an oxide of zinc ointment, with a drachm 
of calomel to the ounce, or Lassar paste may be kept 
in contact with the lesions. After the disease has 
become chronic, and inflammatory thickening is present, 
a resorcin and bichloride of mercury lotion seems to 
have a better effect, and an ammoniated mercury oint- 
ment half strength kept applied at night. In some 



184 LECTURES IN DERMATOLOGY. 

cases I have had very good success in using a sulphur 
lotion applied several times during the day, and the fol- 
lowing sulphur ointment once every three or four days 
for an hour or more : 

R Sapon. virid 3 iii 

Sulphur sub., 

01. cadini aa 3 iss 

Petrolat i . 3 iii 

m 

Depilation is recommended by many dermatologists of 
all the hairs seemingly affected, but this does not seem 
necessary except in a few cases. It is well in all cases, 
when the disease seems to spread, to remove all the 
affected hairs in the periphery of the patch, for this seems 
often to check the extension of the trouble. If it does 
not, tincture of iodine or acetic acid may be painted about 
the borders of the patch every two or three days. 



LECTURE XIII. 

5 YPHIL DERM A TA . 

Gentlemen : 

Syphilis, except so far as the cutaneous manifestations 
of it go, belongs to another chair than mine, and I will 
therefore not take up your time with the consideration of 
either primary or constitutional syphilis, but simply skin 
syphilis or syphiloderma. 

There are many varieties of syphilis affecting the skin, 
but they all present some symptoms and certain general 
features which we may first consider as common to them 
all. In the first place we usually have a history of an ini- 
tial lesion, and although this symptom should not be too 
closely relied upon, as the chancre may not be recognized 
either by the patient or physician as such, nevertheless 
the history of such a lesion can usually be obtained. In 
the second place we have certain constitutional symptoms 
present with the eruption. The most common of them 
are headache, muscular pains, pains in the bones, which 
pains are almost always worse at night, enlarged inguinal, 
epitracheal, and cervical glands, chronic sore-throat and 
alopecia, and after the first year bone and nerve lesions 
which are quite characteristic. In the third place syphilitic 
lesions are rarely accompanied by either itching or burning 
sensations, and unless irritated are not usually painful. 
This absence of subjective sensations is quite characteristic. 
In the fourth place the early syphilitic lesions are usually 
185 



1 86 LECTURES IN DERMATOLOGY. 

distributed and symmetrically arranged, while the later 
lesions are less numerous and symmetrical, and show a 
decided tendency to circular and concentric or serpigi- 
nous arrangement. In the fifth place all syphilitic erup- 
tions and lesions, are usually of a copper or dark brown 
color, which aids us in distinguishing them from any other 
lesions. Lastly, there is a great tendency to multiform- 
ity of the lesions, making their appearance at or about the 
same time, although one form is decidedly in predomi- 
nance. Polymorphism is, however, much more apt to be 
seen in the earlier manifestation of syphiloderma, although 
it does occur in the later stages. Thus you see we have 
a good many symptoms in common to all syphilitic erup- 
tions, and which aid us in making a correct diagnosis. 

The different forms of syphiloderma are the erythema- 
tous, papular, papulo-squamous, pustular, tubercular, gum- 
matous, and the pigmentary. The vesicular and bullous 
forms are occasionally met with, but so very rarely that 
I will not consider them at present. 

ERYTHEMATOUS SYPHILODERMA. 

Synonym — Macular Syphilide. The erythematous syphi- 
lide is the earliest of all the syphilodermata. It gener- 
ally makes its appearance in about six or eight weeks 
after the chancre. It is the only variety of syphiloderma 
ushered in with constitutional symptoms called syphilitic 
fever. These symptoms consist of general malaise, fever, 
general muscular pains, and headache, which last more 
than two or three days. There may be, however, no con- 
stitutional symptoms accompanying the eruption. The 
lesions first show themselves in the neighborhood of the 
umbilicus and from there spread all over the body, except 
on the face and backs of the hands and feet. • The trunk 



PAPULAR SYPHILIDE. 1 87 

and flexor surfaces of the extremities are especially 
attacked. The lesions consist of macules usually about 
the size of the finger nail, round or irregular in shape. 
They are of a dark reddish color, more marked on ex- 
posure to the cold, giving the skin a mottled appearance. 
They usually last from three to four weeks, gradually 
fading with slight desquamation, and leaving a slight 
pigmentation, which entirely disappears after a time. 
Relapses are common during the first year, but occasion- 
ally seen during the second year of the disease, the erup- 
tion being generally less copious with each relapse. 

Diagnosis. The macular syphilide must be diagnosed 
from pityriasis rosea, simple roseola, tinea versicolor, ery- 
thematous eczema, and the medicinal eruptions. 

PAPULAR SYPHILIDE. 

There are several distinct varieties of the papular syphi- 
loderm which require separate description. They are : 

I. Small papular sypJiilide (synonym — miliary papular 
syphilide and lichen syphiliticus). This variety of syphi- 
loderm may occur early or late in the disease, but seldom 
before the fifth or sixth month. It runs a very chronic 
course, being the least affected of all the syphilitic erup- 
tions by treatment. It makes its appearance about the 
shoulders, trunk, arms, and thighs, either in a disseminate 
manner or in groups very thickly studded. The lesions 
consist of minute, confluent papules, pin-head or millet- 
seed size. They are hard, elevated, acuminated, and 
often scaly. In color they are dark-red or copper. They 
last for weeks before they disappear, leaving a pigmenta- 
tion which lasts for a long time. 

II. Large papular syphilide. This form of the eruption 
is very common, and usually makes its appearance early 



1 88 LECTURES IN DERMATOLOGY. 

in the disease — third or fourth month — but relapses are 
common even after the second year. It usually follows 
immediately after the erythematous variety. The erup- 
tion may show itself upon any portion of the body, or the 
forehead, neck, back, flexor surfaces of the extremities, 
and genital regions are especially liable to be attacked. 
The lesions consist of large flat papules, varying in size 
from a split-pea to a finger nail. They are round or oval 
in shape, firm, and circumscribed. They are distinctly a 
raw-ham color, and disappear easily with treatment. 
These large papules are apt to undergo changes so that 
they become altered in appearance and form. 

(a) At times they become soft and spongy, showing- 
signs of excoriation and crusting over. When they exist 
about the corners of the mouth or anus, or other parts 
exposed to moisture, deep, painful fissures often occur. 

(b) The most common change in the papule, however, 
is into the moist papule (also called the mucous or condy- 
lomata). This change takes place where moisture natu- 
rally exists, as about the mouth, throat, genitals, breasts, 
and axilla. When moisture and friction exist between 
two opposing surfaces these lesions are very apt to occur, 
as between the nates or labia, or between the toes. The 
lesions differ from the large, dry papules by being moist, 
and covered with a gray, mucous secretion consisting of 
macerated epidermis. They are flattened, less circum- 
scribed, and often larger than the dry papules. They are 
also soft and spongy and often run together, producing 
patches of considerable size. Occasionally the surface 
becomes covered with hypertrophied papillae, when the 
term vegetating syphiloderma is applied. These often 
crust over, and are most frequently seen about the edges 
of the scalp or genitals. You must remember that the 



PAPULOSQUAMOUS SYPHILODERMA. 1 89 

secretion from these moist papules is very contagious, 
often more so than the chancre itself. Although not 
auto-inoculable, the secretion coming in contact with an 
opposing surface is very apt to light up a similar lesion in 
that location. If properly treated they disappear readily 
in most cases. 

Diagnosis. The papular syphilide may be mistaken for 
keratosis pilaris, lichen planus, acne, psoriasis, lichen scrofu- 
losis, and possibly for papular eczema. The moist papule, 
or condylomata, is frequently confounded with simple 
stomatitis, hemorrhoids, epitheliomatous ulcers, and vene- 
real warts. 

PAPULO-SQUAMOUS SYPHILODERMA. 

Synonym — syphilitic psoriasis. These lesions, although 
they may occur elsewhere on the body, are especially apt 
to attack the palms or soles. When occurring on the body 
they consist of a number of grouped, flattened papules, 
covered with dry, greasy, adherent scales. The scales, 
although never so abundant as in psoriasis, give the ap- 
pearance of a single lesion, but when removed the patches 
will be seen to consist of a number of grouping papules 
of a distinctly raw-ham color. The eruption is rarely ex- 
tensive, and seldom symmetrical as in psoriasis. When 
the lesions are on the palms and soles the term palmar 
and plantar syphiloderma are used. The lesions are more 
like slightly raised macules than papules, of split-pea or 
finger-nail size, which show a decided tendency to coa- 
lesce into rounded or serpiginous patches. These patches 
are covered with scales, sometimes more abundant than 
others, but also more abundant on the borders of the 
patch. If the scales are removed the raw-ham color be- 
neath is very apparent, and often presenting painful, deep 



190 LECTURES IN DERMATOLOGY. 

fissures. The disease spreads often from the centre 
toward the periphery by a distinctly elevated border, 
but not completely disappearing at the centre, which re- 
mains scaly. The eruption is almost always limited to 
the palms and soles, not spreading to the wrists or backs 
of the hands. If the lesions occur early in the disease 
the eruption is usually symmetrical, but if late in the dis- 
ease but one hand or foot is usually attacked. The dis- 
ease is very chronic, lasting months or years, not readily 
yielding to treatment. The disease is often difficult to 
diagnose from palmar psoriasis and eczema. 

PIGMENTARY SYPHILODERMA. 

You must not confuse pigmentary syphiloderma with 
the pigmentation in the skin the result of some syphilitic 
eruption. The majority of syphilitic eruptions are fol- 
lowed by pigmentary deposit at the seat of the skin 
lesion, but this is not true of pigmentary syphiloderma, 
which is never secondary to any other eruption. True 
pigmentary syphiloderma occurs almost exclusively in 
women, and in the second year of the disease. It seldom 
occurs elsewhere than upon the neck. The disease con- 
sists of circumscribed, delicate coffee-and-milk-color pig- 
mentations of the skin, in the form of irregular-shaped 
finger-nail-sized macules, often coalescing, giving the 
appearance of delicate network, sometimes described as 
the "queen's veil." It lasts for several months, and is 
not relieved by treatment. It is undoubtedly a form of 
chloasma influenced by syphilis, but must be carefully 
diagnosed from simple chloasma. 

PUSTULAR SYPHILODERMA. 

There are several varieties of pustular syphiloderma 
which require separate description. 



PUSTULAR SYPHILODERMA. ICjt 

I. Small or miliary pustular syphilide. This usually oc- 
curs early in syphilis. It may even be the first eruption 
noticed, but in the form of relapses it may occur late in 
the disease. The back and extremities are the favorite 
locations for the eruption, when it usually invades large 
areas of surface either in groups or disseminated. Oc- 
casionally it occurs in circles. The lesions are pointed 
and millet-seed in size, and situated on reddish, papular 
elevations. The pus, which is in small quantity, dries, 
forming small yellowish crusts, which fall off, leaving 
little pits lasting for some time. Slight desquamation 
takes place about the pits, forming a collar called by the 
French " collarette." The seat of this disease seems to 
be in or about the hair follicles, as most of the lesions are 
punctured by a hair. 

II. Large or acne-form pustular syphilide. This also 
is an early pustular eruption, and when it first makes its 
appearance is not infrequently accompanied by fever and 
headache. The lesions appear upon the face, scalp, and 
trunk, sometimes upon the extremities. The lesions be- 
gin as small, split-pea-sized papules, which within twenty- 
four hours or three days become pustular. This pus 
dries into brown scabs, which are situated upon superficial 
ulcers. These crusts fall off in a few days, leaving pits 
with considerable pigmentation. The lesions are quite 
numerous and often grouped. Not infrequently this 
form of syphilide is mistaken for small-pox, and vice versa. 
It runs a rapid and benign course. 

III. Small, flat, pustular syphilide or impetigo syphilitica. 
This eruption is usually about the hairy portion of the 
face and scalp. The lesions are small and flat, and grouped 
into irregular patches. Crusts form almost immediately, 
so that the pustular nature of the lesion can hardly be 



192 LECTURES IN DERMATOLOGY. 

appreciated. These crusts are yellowish and thick, and 
when forcibly removed a superficial ulcer will be found 
beneath. The lesions look very much like pustular eczema, 
but may be diagnosed by the absence of itching and ulcer- 
ation. The lesions run a rapid course, but yield readily to 
treatment. 

IV. Large, flat, pustular sypJiilidc or ecthyma syphilitica. 
This eruption is seen in two varieties : (a) superficial, (b) 
deep. 

(a) This variety is very common, and usually occurs 
about the sixth month of the disease. The lesions are 
numerous, and especially apt to appear upon the back. 
They are finger-nail-size, pustular, flat, and seated upon 
a deep red base. Crusts form almost immediately. They 
are yellowish or brownish in color, flat and round, seated 
upon superficial ulceration. 

(b) The deep variety is a late manifestation of syphi- 
lide, and occurs upon the extremities. They are usually 
as large as a thumb nail, and surrounded by an inflamed, 
indurated area. The crusts are of a blackish color, conical 
and striated like an oyster shell, and constitute what is 
known as rupia. There is deep ulceration beneath the 
crusts, which discharge large quantities of greenish pus. 
These crusts when they fall off leave large scars deeply 
pigmentated. 

Diagnosis. There are so many varieties of the pustular 
syphilide that it is not always easy to make a diagnosis 
until you have carefully examined the patient several times. 
It is most apt to be mistaken for ecthyma, impetigo, 
small-pox, sycosis, acne, and pustular eczema. 

TUBERCULAR SYPHILIDE. 

Tubercular syphilide is a late manifestation of the 
■disease, seldom occurs before the second year, and may 



GUMMATOUS SYPHILIDE. 1 93 

be delayed for many years. It usually attacks the face, 
shoulders, and back. The lesions are usually not very 
numerous, and appear almost always in groups, forming 
rounded patches or segments of circles. Several of such 
segments may unite and form a serpiginous, tubercular 
syphilide. The individual lesions consist of solid eleva- 
tions in the skin of split-pea size. They are firm and 
circumscribed, deeply seated in the skin, and distinctly 
copper color. The lesions spread from the centre toward 
the periphery. They disappear either by absorption or 
ulceration. When ulceration takes place each lesion is 
completely destroyed, leaving unsightly scars, as the 
whole patch is apt to undergo destruction. The edges of 
the ulceration are irregular and uneven. The ulceration 
often runs a serpiginous course, spreading from the centre 
toward the periphery. As the ulceration spreads, cicatri- 
zation takes place, so that frequently there is a furrow of 
ulceration surrounding a patch of cicatrization. The pro- 
cess is a slow one both in development and spreading, 
but yields readily to treatment. 

Diagnosis. The diagnosis of the tubercular syphilide is 
usually much easier than the pustular form. When it 
occurs about the face, however, it often is mistaken for 
lupus vulgaris, rosacea, or for leprosy in countries where 
leprosy is a common disease. Occasionally it is mistaken 
for epithelioma. 

GUMMATOUS SYPHILIDE. 

Synonym — gumma, gummy tumor. This variety of 
the disease is usually one of the latest manifestations of 
syphilide, but occasionally occurs during the first year of 
the disease, when it is known as precocious gummata. 
The lesions are few in number, seldom more than two or 
three at a time. They most always develop in the loose, 



194 LECTURES IN DERMATOLOGY. 

soft tissues, as upon the sides of the thorax and abdo- 
men, about the sternum, and upon the flexor surfaces of 
the extremities. The lesions begin as small, pea-sized, 
painless bodies, which are flattened beneath the skin. 
They increase slowly in volume, taking weeks before they 
are characterized as flat, circumscribed, subcutaneous 
tumors, about the size of a walnut, slightly raised above 
the surface of the skin. At first they are firm in consist- 
ence, but afterwards soft, owing to a destructive process. 
The skin then becomes involved, and appears pinkish or 
reddish. As the gumma breaks down it ulcerates and 
destroys the tissues in which it has its seat, leaving a 
circumscribed, deep excavation, rounded in form, with 
perpendicular edges. Its bottom is uneven and covered 
with a grayish, gummy deposit. Although the destruc- 
tive process is generally considerable, the ulcer heals by 
cicatrization, leaving often but a slight scar. Occasionally 
these gummy tumors heal by absorption without ulcera- 
tion. 

Diagnosis. A differential diagnosis must be made 
between the gummous syphilide and other forms of 
tumors, erythema nodosum, and abscesses. When syphi- 
litic lesions break down and form ulcers, it is very im- 
portant for you to distinguish them from other forms 
of ulceration. 

Treatment. The constitutional treatment of syphilis 
with mercury, iodine of potash and tonics belongs to 
another chair than mine, but I will say a few words as to 
the best forms of local applications in some of the 
syphilides. 

The macular syphilide may be hastened in its disappear- 
ance by taking a hot bath every day, or better still a 
Turkish bath, using the tincture of green soap in prefer- 



GUMMATOUS SYPHILIDE. 1 95 

ence to any other. Immediately after the bath the erup- 
tion is frequently more pronounced, but it fades gradually 
and eventually disappears without any other external 
application. 

In the small papular syphilide there is nothing which 
will cause the disappearance of the lesion so rapidly as 
a mercurial vapor bath. If the eruption is confined to 
small areas, nightly inunctions of the ammoniated mer- 
cury ointment to these areas is followed by the best 
results. 

In the large scaly syphilide alkaline baths (one-half 
pound of bicarbonate of soda to fifteen gallons of hot 
water) every night, followed by inunctions to each lesion 
of the ammoniated mercury ointment, or better still, if 
possible, the continued application of the ointment spread 
on lint to these lesions, will give great satisfaction. After 
the papular character of the lesion has disappeared the 
stain will often remain for a long time. To remove the 
pigmentation the following lotion may be applied 
frequently: 

5. Hydrarg. chlor. corros. . . . gr. iv 

Ammonii chlor gr. x 

Aquae rosae | iv 

m 

The scaly syphilides are often very rebellious to treat- 
ment, especially when they attack the palms or soles. 
The scales should first be softened by soaking them with 
a solution of caustic potash, half a drachm to the ounce 
of water, then thoroughly dried, and the ammoniated 
mercury ointment containing a drachm of the oil of cade 
to the ounce, kept continuously applied. This treatment 
should be repeated daily unless the lesions become in- 



196 LECTURES IN DERMATOLOGY. 

flamed, when a soothing ointment, preferably Lassar's 
paste, should be applied for a few days. In those cases 
where the scaling is especially marked, often taking on 
the appearance of psoriasis, and consequently called 
syphilitic psoriasis, chrysarobim ointment in the strength 
of five to ten per cent, rubbed into the lesions or kept 
applied to them, will be followed by great benefit. Care, 
however, must be taken to limit the action of the drug to 
the lesions, otherwise a severe dermatitis may be set up. 
The small, pustular syphilide requires but little external 
treatment. Removing the scabs with an alkaline lotion, 
and applying a salve, composed as follows, will be all that 
is required : 

$ Ung. hydrarg. nit 3 ii 

Vaseline § i 

The scabs from the large pustular syphilide and other 
forms of ulcerating t?ibercular syphilide must first be care- 
fully removed by poulticing — or hot alkaline solutions — 
before any treatment is undertaken. After the scabs are 
removed, the base of the ulcers should be slightly touched 
with carbolic acid, and then dusted over with iodoform or 
calomel. If granulations exist they should be touched 
with a stick of nitrate of silver. If the ulcerations remain 
sluggish and show no disposition to heal, an ointment 
consisting of — 

# Bals. Peru 3 ss 

Ung. hydrarg. ammon., 

Vaseline aa § ss 

m 

May be applied with benefit. 



HEREDITARY SYPHILIS. 1 97 

Do not excise a gumma. They frequently can be ab- 
sorbed by the continuous application of the mercurial 
plaster or ointment, even after they have softened and 
appear to be broken down. When the lesions do break 
down and ulceration exists, healing will not take place 
until the neurotic tissue is all destroyed. This can be 
hastened by frequently washing the ulcer with a solution 
of caustic potash, a drachm to the ounce, and dusting 
with iodoform and poulticing. After the granulations 
become healthy you may employ the same treatment 
recommended in the ulcerating syphilis. 

HEREDITARY SYPHILIS. 

It has long been a disputed question whether syphilis 
could be transmitted from a syphilitic father to the child 
without the mother being affected. Until recent years 
this has generally been considered as possible, but lately 
this fact has been questioned by most careful observers. 
The more the question is studied and investigated the 
more certain it becomes that true hereditary syphilis must 
be contracted through the mother. So confident am I 
that syphilis cannot be transmitted from the father to the 
child, that I now have no hesitancy in letting my male 
patients marry after all danger of communicating the 
disease to the wife has passed, and I have yet to see the 
first syphilitic child as the result of such union. A child, 
the subject of hereditary syphilis, may be born perfectly 
free from all appearance of disease, or the disease may be 
stamped upon it before it enters the world. In the 
majority of cases the child is born perfectly healthy. 
Before the end of the first month, however, the disease 
usually manifests itself, and almost without exception 
before the end of the fourth month, so that if there is no 



198 LECTURES IN DERMATOLOGY. 

evidence of syphilis before that period the child is almost 
certain to escape the disease. When a child is born 
syphilitic the lesions are either maculo-papular or bul- 
lous, and the child shows the general signs of syphilitic 
cachexia, marasmus, and coryza, seldom living more than 
three weeks. 

When born healthy in appearance the syphilitic child 
soon begins to lose flesh, the skin assumes a muddy hue 
and becomes wrinkled, hard, and dry, giving the patient 
a pinched, weazened appearance of an old man or woman. 
The first specific symptom noticed is coryza, the acrid 
discharge stopping up the nostrils, giving the baby the 
snuffles. This discharge, after a time, becomes bloody 
and fetid, excoriating the surface with which it comes in 
contact. Do not mistake the snuffles of a syphilitic child 
for the ordinary cold in the head with which young chil- 
dren are very apt to suffer. If you do, and tell the parents 
that their child is syphilitic and it proves afterwards not 
to be so, you are likely to get yourself disliked by the 
family. If the coryza has lasted for some time, the 
bones of the nose may become affected and necrose. 
The inflammation may extend to the larynx and pro- 
duce a laryngitis. Soon after the coryza is noticed 
the skin lesions begin to form. The first one noticed is 
usually the macular syphilide, appearing as irregular, 
erythematous patches about the size of a finger nail 
upon the buttocks and genitals. They often run to- 
gether, producing a continuous patch of erythema ex- 
tending down the thighs, giving a distinctly copper 
color, which will help you to distinguish it from inter- 
trigo. The erythema surface often becomes excoriated, 
looking like eczema, but before long erythematous 
patches appear elsewhere, as upon the palms and soles, 



HEREDITARY SYPHILIS. 1 99 

which are accompanied by more or less exfoliation. 
After a few weeks the lesions take on a papular character, 
the eruption becoming maculo-papular, which is the most 
common syphilide in infants. The papules are broad and 
flat^ becoming moist papules about the mucous surfaces, 
as the mouth, anus, and genitals, or wherever heat, 
moisture, and friction exist. 

The bullous syphilodcrma is most frequently seen at 
birth, but may occur later. It consists of flat, irregular- 
shaped bullae, showing a decided tendency to attack the 
palms of the hands and soles of the feet. They are sur- 
rounded by an inflammatory areola, and when broken 
down or ruptured show an excoriated, ulcerated base, 
which heals veiy slowly. New blebs form from time to 
time as the old ones disappear. The lesions do not usually 
appear alone, but associated with the papulo-macule 
eruption. The condition of the child's teeth, the diseases 
of the bones, as dachylitis, and other symptoms besides 
the eruptions on the skin, will all aid you in making a 
correct diagnosis. 

The treatment of syphilis in infants should always be 
heroic. Syphilitic children if left to themselves without 
treatment always die, and that within a short time. In- 
unctions of mercury in the milder cases, and the hypo- 
dermic injections of mercury in the severer cases, are the 
forms of treatment which should be most relied upon. 

The local treatment which I suggested in the treatment 
of syphilis in adults should guide you also for the local 
treatment in the syphilis of infants ; but remember that 
the skin of infants is very much more delicate than that 
of adults, and the preparations employed must conse- 
quently be milder, and you must be governed very largely 
by the local effect produced. 



LECTURE XIV. 

TINEA. 

Gentlemen : 

To-day we will study the so-called vegetable parasitic 
skin diseases, or tinea. There are undoubtedly a large 
number of vegetable parasites which attack the skin and 
produce well marked symptoms, but there are but three 
varieties which are recognized by all dermatologists, and 
to these I will ask your attention. They are named 
tinea favosa, tinea trichophytina, and tinea versicolor. 
These are all very contagious. 

TINEA FAVOSA. 

Tinea favosa, or favus, as it is generally called, is in 
this country the least often seen. It is, however, very 
common in Italy and Russia, and it is among these emi- 
grants that we most frequently meet with it. The disease 
is almost always limited to the scalp. 

Pathology. The disease is due to a vegetable parasite 
called the Achorion Schoenleinii. The fungus consists of 
mycelial threads 1-800 of an inch in diameter, and small, 
round, or flask-shaped spores. These gain access to the 
skin through the hair follicles, attacking the hair sac and 
spreading outward between the superficial layers of the 
epidermis. Afterwards it attacks the hair shaft itself. 
The growth of this fungus causes the loss of hair and 
atrophy of the skin. 



TINEA FAVOSA. 201 

Symptoms. The disease either begins as scaly, erythema- 
tous patches, or in the form of small, yellowish, punctate 
spots appearing on the scalp. These develop into small, 
yellowish, cup-shaped crusts about the hairs, and are 
usually the size of a split pea. These crusts are first 
covered with a thin layer of the epidermis, and are conse- 
quently difficult to remove, and when torn off cause some 
bleeding. The hairs in and about these crusts are dry, 
brittle, and lustreless, falling out in places, leaving bald 
spots. The crusts may be few or many, usually discrete, 
although they may coalesce. They are very firm to the 
touch, dry and crumble like mortar between the fingers. 
If the disease has lasted for a time these yellowish cup- 
shaped crusts are sometimes obscured by the pressure of 
a thick, mortar-like substance, which surrounds and covers 
them. There is always a peculiar odor of mice about 
favus, which is so characteristic that you can often diag- 
nose the disease with your sense of smell. With this 
crusting there is always some itching, but not usually 
very great. The disease advances very slowly, new crusts 
forming from time to time, while the old ones drop or are 
torn off, leaving bald patches of atrophied skin, at first of 
a red color, but afterwards turning abnormally white like 
scar tissue, and covered with a loosely adhering epidermis, 
which is easily wrinkled under the finger. The irregular 
bald areas contain here and there a few hairs, which are 
dry, lustreless, and wire-like. When the crusts or scutula, 
as they are sometimes called, are removed, they usually 
form again in two or three weeks. The disease lasts for 
years unless treated, and sometimes even then. Although, 
as I told you, it is usually limited to the scalp, it oc- 
casionally attacks the skin or nails. 

Diagnosis. If you find the characteristic fungus with 



202 LECTURES IN DERMATOLOGY. 

the aid of the microscope, of course your diagnosis is 
made certain. You should always use the microscope 
whenever you suspect the presence of favus, for the dis- 
ease is often mistaken for seborrhcea, eczema, psoriasis, and 
lupus erythematosus. You also must be able to diagnose 
the baldness resulting from this disease from other forms 
of alopecia. 

Treatment. Never pronounce a case of favus cured 
until all signs of the disease have disappeared for three 
months. In the first place you must get rid of all crusts 
by the aid of salicyliated oil or poultices ; after that you 
must every night rub into the affected area some strong 
parasiticide. The following is the one which I have found 
the most beneficial : 

5 Acid, carbolici gr xv 

Bals. Peru 3 ss 

Ung. hyd. nit., 

Sulphur, sub aa 3 i 

Petrolat I i 

m 

If a dermatitis is set up you will be obliged to stop this 
active treatment for a few days, and employ some sooth- 
ing application as ointment of roses. 

TINEA TRICHOPHYTIXA. 

Tinea trichophytina, or ringworm, is a vegetable para- 
sitic disease produced by a micro-organism called the 
trichophyton, which may attack either the body, the 
scalp, or the beard. Although the cause is the same in 
the three affections, the appearance of the lesions, the 
symptoms, and treatment are so different, that they each 
demand a separate description. 



RINGWORM OF THE BODY. 203 

RINGWORM OF THE BODY. 

Is usually described under the name of tinea circinata 
or herpes circinatus. It is due to a fungus which, alight- 
ing upon the skin, finds its way into the epidermis, but 
does not penetrate the true skin. Under the microscope 
the fungus is seen imbedded in the epidermic cells in the 
form of slender, ribbon-like formations or threads, called 
mycelium, containing granules called spores. These 
mycelium are long and branching, often forming a net- 
work. The spores may be isolated as well as joined to 
the mycelium. 

Etiology. The disease is very contagious, and fre- 
quently is communicated from one person to another. 
Domestic animals, as cats, dogs, and, horses, are affected 
with ringworm, and frequently the source of the conta- 
gion. Children are more susceptible to the disease than 
adults, and some persons very much more so than others. 
It is doubtful if the disease is communicated by mere 
touch, but probably the parasite is carried by means of 
damp towels, sponges, or clothing, and coming in contact 
with a skin susceptible to the contagion the trichophyton 
becomes implanted and multiplies rapidly. 

Symptoms. The disease usually first shows itself as a 
small scaly, rounded spot of a dull red color, slightly itchy, 
and occurring upon any part of the body, but most 
frequently upon the face, hands, and neck. The lesion 
gradually enlarges from the centre towards the periphery 
by a circular border, slightly elevated, well defined, and 
scaly. This border if carefully examined will be found to 
be attended with the formation of minute papules or 
vesico-papules. As these patches increase in size the 
centre of the lesion has a tendency to clear up, although 
they still remain somewhat scaly and dull reddish in 



204 LECTURES IN DERMATOLOGY. 

color, and often containing a few pustules. It takes 
about a week or ten days for the patches to reach their 
full development, which is usually about the size of a 
silver half dollar. There are usually not more than two 
or three such patches present on the body and they 
remain discrete, but occasionally a number are present 
coalescing, producing irregular-shaped patches with curved 
outlines, assuming the form of serpiginous lesions. The 
scales, which are always most abundant about the margin 
of the lesion, are adherent and shreddy, and contain the 
parasite. The disease is accompanied by slight itching, 
more marked in some cases than others. 

Course. Ringworm, if not treated, usually lasts a few 
weeks and disappears. Occasionally it lasts for months 
or years, the lesions disappearing and returning again in 
the same locality, or on different parts of the body. 
When they last for months or years the lesions lose some 
of their characteristics and become small, superficial, less 
scaly, and irregularly shaped. 

Diagnosis. If there is any doubt as to the diagnosis 
of the disease scrape off a few scales from the suspected 
patch, mix with a drop of liquid potassae, and examine 
under the microscope for the mycelium and spores. They 
may be plainly seen with a power from 250 to 500 di- 
ameters. This will aid you very much in diagnosing ring- 
worm from pityriasis rosea, seborrhcea, psoriasis, squa- 
mous eczema, erythematous lupus, and syphilis. 

Treatment. As frequently ringworm occurs in debili- 
tated subjects internal tonic treatment may be required, 
especially if the disease shows a tendency to become 
chronic or to return. External treatment is usually all 
that is required. Hundreds of remedies have been pre- 
scribed for ringworm, but I will mention but three — chry- 



ECZEMA MARGINATUM. 205 

sarobin paint, bichloride of mercury, and tincture of 
iodine, either one of which will usually cure the disease. 
Before any of these applications are applied the patch 
should be thoroughly scrubbed with soap and hot water. 
The chrysarobin paint is prepared as follows : 

# Acid, salicylic 3 ss 

Acid, chrysophanic 3 i 

Liq. gutta percha § i 

This paint should be applied every second day. Two 
or three applications are usually sufficient. If the corro- 
sive sublimate solution is used, it should be applied with 
a brush night and morning and allowed to dry on the 
surface. The strength should be about two grains to the 
ounce. If the iodine is used, the patch may be painted 
with it every second day for three or four applications. 
If this treatment sets up a dermatitis, soothing applica- 
tions of zinc salve may be required for a few days. After 
following out such a plan of treatment as I have sug- 
gested it is well to wait for a week or so and watch the 
result. Occasionally two or three more applications may 
be necessary, but not often. 

ECZEMA MARGINATUM. 

This is a form of ringworm of the body described by 
Hebra under the name of eczema marginatum, which 
occurs about the fork of the thigh, groin, and axilla, and 
differs in many respects from the lesions already de- 
scribed. The disease usually begins with a reddened, 
thickened patch of skin, with a marginate border, sharply 
defined and irregular. The patch increases in area from 
day to day, with very little tendency to clear in the 



206 LECTURES IN DERMATOLOGY. 

centre, until they reach the size of a dollar or larger. 
Several of these patches usually make their appearance 
in the regions mentioned, and coalescing invade a large 
area of skin. The process is accompanied by an eczema, 
or more properly a dermatitis, as shown by the redness, 
thickening, exudation, and desquamation of the patches. 
There is a great deal of itching present, and sometimes 
burning and pain. The disease runs a chronic course, 
and is often rebellious to treatment. If the disease has 
lasted but a few days, you may be able to effect a cure 
with the treatment already given, but when the disease 
has become chrpnic, or will not yield to milder forms of 
treatment, we must resort to other measures. I have 
had good results during the past year in treating these 
cases as follows : After first cutting the hair off the 
patch I have it cleansed thoroughly with soap and hot 
water containing a little washing soda. After drying 
thoroughly, the border of the lesion is painted over with a 
solution of equal parts of chloral, carbolic acid, and tinc- 
ture of iodine, and the whole patch lightly gone over 
with the same. To relieve the pain caused by this 
application a 2 per cent, cocaine ointment is applied 
for an hour or so, and then an ointment kept on con- 
tinually composed of — 

IJ Ung. picis, 

Ung. ac. carb aa 3 ii 

Ung. diachylon ad 3 i 

m 

Every two or three days, occasionally not so often, 
owing to the irritation produced, this treatment is to be 
continued until a decided improvement is noticed, when 
the ointment alone can be applied. Usually six or eight 



TINEA TONSURANS. 2Q-] 

applications of the iodine solution will be sufficient. After 
a cure is effected, it is well to have your patients use a 
wash for some time to the affected area, composed of one 
grain of the bichloride of mercury to an ounce of rose water. 

TINEA TONSURANS. 

Tinea tonsurans, or ringworm of the scalp, is produced 
by the same parasite which causes ringworm of the body, 
and it not only involves the epidermis, but the hair and 
hair follicles as well. The hairs and their follicles become 
filled with the spores and a few mycelium, distending and 
rupturing them. The hair bulbs are also distended with 
spores, which are also sometimes found in the corium. 

Etiology. Ringworm of the scalp, like that of the body, 
is a highly contagious affection, and communicated from 
one person to another by means of towels, brushes, combs, 
caps, etc. It attacks only children, being seldom seen in 
persons over fourteen or fifteen years of age. A ringworm 
on the body of a mother will frequently communicate 
ringworm to the scalp of her child, the parasite in both 
cases being the same. 

Symptoms. The disease usually begins very much in 
the same way as does ringworm of the body, with the 
presence of an irregular, scaly, erythematous patch on 
the scalp. In a few days it begins to spread from the 
centre toward the periphery, with a raised, red, circular 
border, which is very apt to consist of small vesicles or 
pustules, which terminate in furfuraceous scales or des- 
quamation. These patches grow rapidly, usually attain 
the size of a silver dollar, and present the following 
characteristic features : each lesion is elevated, circular, 
circumscribed, of a reddish or bluish color, and covered 
with dry, furfuraceous scales. The hairs in the patch are 



208 LECTURES IN DERMATOLOGY. 

scanty, broken, split, or deformed, and their follicles 
prominent, giving the surface a goose-skin appearance, 
especially marked if the disease has lasted for some time 
and most of the hairs have fallen out. The hairs are 
not only deformed, but are dull, lifeless, brittle, and very 
liable to drop out or to break off close to the follicles, 
producing baldness, and making the patch feel like a nut- 
meg grater. Some of the hair follicles undergo a sup- 
purative process, and then you will find pustules in the 
lesion, which rupture and form crusts. Occasionally the 
whole patch becomes acutely inflamed, red, and infil- 
trated, pitting on pressure and crusting, looking like an 
eczema of the scalp. This condition is known as kerion. 
Any portion of the scalp may be affected, but most fre- 
quently over the parietal region. There are usually not 
more than two or three lesions present at one time, 
but these may run together, producing large, irregular 
patches. Occasionally the whole scalp is attacked. The 
disease may spread to the side of the face, when it 
becomes tinea circinata. 

Course. If ringworm of the scalp is permitted to run 
on without treatment it lasts indefinitely, but frequently 
ends in spontaneous recovery. 

Diagnosis. Ringworm of the scalp may be mistaken 
for eczema, seborrhcea, alopecia areata, or psoriasis, but 
the history of the contagion, the deformity of the hair, 
and the presence of the parasite shown under the micro- 
scope will usually settle the diagnosis. The microscopic 
examination of the parasite is the same as for ringworm 
of the body. 

Treatment. The same remedies recommended for ring- 
worm of the body may be employed in ringworm of the 
scalp. The disease, however, is much harder to cure. The 



TINEA BARBAE. 20O, 

hairs in and about the borders of the patch should be 
carefully removed, and the scalp scrubbed with soap and 
water before treatment is applied. I have had the best 
success in treating these cases by applications, about 
every few days, of a solution of equal parts of pure car- 
bolic acid, tincture of iodine, and chloral. This should 
be painted over the lesions, and a little beyond the bor- 
der, with a camel's-hair brush. As dermatitis is usually 
set up for the next two or three days, the disease seems 
very much worse. I limit this inflammation by the con- 
tinued application of Taylor's paste, which is made as 
follows : 

5, Camphorae gr. xx 

Ung. aq. rosae % i 

m 

which will be found very efficacious. Three or four appli- 
cations of the acid is usually sufficient to effect a cure. If 
the disease is very extensive, it is best to treat only a 
portion of it at a time with the carbolic acid solution for 
fear of causing too much inflammation of the scalp or 
absorption of the drug. While you are treating one patch 
with carbolic acid, you may be making application of the 
alkaline sulphur ointment to another. In young infants, 
care must be taken to use not too strong applications to 
the skin, and if carbolic acid or tincture of iodine is used, 
they had better be diluted with alcohol. To prevent in- 
fection to other portions of the scalp, a solution of bichlo- 
ride of mercury, two grains to the ounce of bay rum, is 
very serviceable. 

TINEA BARBAE. 

Tinea barbae, barber's itch, or parasitic sycosis are the 
terms used to distinguish ringworm when it attacks the 



2IO LECTURES IN DERMATOLOGY. 

beard. The parasite is the same trichophyton that we 
have already studied incases of ringworm of the body and 
scalp, but its clinical features are very different, owing to 
the anatomy of the part which it now attacks. 

Pathology. The fungus attacks the hair follicles and 
hair shafts, producing a suppurative inflammation, not 
only of the follicles but in the subcutaneous tissue about 
them. Under the microscope the mycelium and spores 
are found abundant in and about the hair root and shaft, 
the hair bulb being often obliterated. 

Etiology. The disease is contagious, but apparently 
less so than ringworm of the body and scalp, and is not 
a very common affection. It occurs most frequently in 
persons between twenty and thirty years of age. The 
name barber's itch is given to this disease because it is 
supposed to be contracted some way in shaving, either 
from the razor, brush, lather, or towel of the operator. 
The probabilities are that the parasite is carried most 
frequently by means of the towel, although it has been 
found by microscopical examination in the shaving-brush, 
especially where the brush has not been used for some 
time and has become mouldy. When a damp towel 
which contains the parasite, by not having been properly 
cleansed and ironed after contact with the face of a person 
suffering from the disease, is used upon a recently shaved 
surface, you can readily understand why the parasite has 
a good chance to enter the hair follicles and start the 
disease. As the parasite is the same in all forms of ring- 
worm, it is not necessary for the fungus to be derived 
from tinea barbae to produce the disease, but it may come 
from either tinea tircinata or tinea tonsurans. 

Symptoms. The disease usually begins as a tinea cir- 
cinata in a reddish, scaly patch on the bearded surface of 



TINEA BARBAE. 2 I I 

the face. In a few days this patch becomes indurated 
and swollen, and the hairs are noticed to become affected, 
they becoming loose, brittle, and broken. In the course 
of a week or more the affected skin becomes distinctly 
nodular and pustules form about the openings of the hair 
follicles. The disease spreads by the presence of new 
patches and increase in size of the old ones. Often these 
lesions run together, producing irregular patches, and in- 
volving large portions of the chin and regions of the 
lower jaw. The upper part of the face and upper lip are 
rarely attacked. After the disease has lasted for some 
time the deeper tissues are involved, giving rise to thick, 
firm, irregular masses of induration called tubercles. The 
surface of the lesion has a purplish or dull red color, and 
studded with pustules. The amount of pustulation 
varies, but often enough to produce considerable crusting. 
If these crusts are removed, the surface beneath will be 
found excoriated and studded with yellowish points, dis- 
charging a glutinous material. The hairs in the affected 
area are brittle or bent, and can be extracted without 
pain. They are often seen to protrude from the centre 
of the pustule. Although the disease has the appearance 
of being very irritable, the subjective sensations are often 
very mild. There is some itching and burning present, 
but never in proportion to the amount of the cutaneous 
injury. 

Course. The disease without treatment usually spreads 
for several weeks, and then remains for months or years, 
then undergoing a spontaneous cure. Relapses are com- 
mon, especially if the disease is not properly cured. 

Diagnosis. The diagnosis of barber's itch is usually 
easy. It may be mistaken, however, for sycosis non-para- 
sitica, pustular eczema, vegetating syphilide, acne indu- 



212 LECTURES IN DERMATOLOGY. 

rata, and seborrhoea. The history of the case, and the 
discovery of the parasite under the microscope will, of 
course, aid you in the diagnosis. 

Treatment. The treatment of barber's itch will require 
patience on your part and on the part of your patient. 
If you see the disease in the beginning, you may perhaps 
check its progress by suitable applications, but if it has 
lasted for weeks, it will take weeks before recovery is 
complete. If the disease has lasted only for a short time, 
you can frequently abort it by a few applications of 
the solution of carbolic acid, iodine, and chloral, that 
was recommended in the treatment of eczema margi- 
natum. This solution should be painted over the diseased 
surface every two or three days, and a soothing appli- 
cation, as Lassar's paste, kept continually on the patches 
to subdue the inflammation. If the disease has lasted 
for some time, you should direct your patient not to 
shave, but to keep his beard cut very close. Many 
dermatologists require that all the hairs should be pulled 
out of the diseased area, but this is painful, and often not 
necessary. All the hairs with suppuration about their 
follicles should be removed always, but more than this 
will seldom be required. Before any application is made, 
all crusts should be removed by means of soap and hot 
water, or by poulticing. Every night and morning the 
patient should bathe the surface for half an hour in very 
hot water. After this all loose hairs or those with pus 
about the roots should be removed. A lotion of 



IJ Resorcini 3 ss 

Hyd. chlor. corr gr. ii 

Glycerini 3 ii 

Aq ad | ii 

m 






TINEA VERSICOLOR. 213 

should be applied and allowed to dry on. At night 
before retiring, an ointment composed of 

3 Resorcini gr. xx 

Ung. hyd. ammon., 

Ung. zinc, ox aa 3 ss 

m 

should be applied to the lesions. 

Occasionally a dermatitis will be set up by this treat- 
ment, and if so it must be discontinued for a few days, 
and Diachylon ointment applied until the inflammation has 
subsided, when the former treatment may be continued. 
Other forms of parasitic ointment or lotions may be 
employed, but the treatment just recommended usually 
gives a good result. During the past few months, I 
have deeply punctured each tubercle in two or three 
places with a dermal spear every few days before apply- 
ing the hot water, and then painted them over with the 
solution of carbolic acid, iodine, and chloral, with most 
gratifying results. 

TINEA VERSICOLOR. 

Under the term tinea versicolor or pityriasis versi- 
color, I wish to describe a very common parasitic skin 
disease, which you have all probably seen a great many 
times, although you may not have recognized it as such. 

Pathology. The disease is due to a vegetable parasite 
called the microsporom furfur. It finds its way into the 
horny layer of the epidermis, and by its growth and 
development produces the symptoms of the disease. This 
parasite consists, as does that of the ringworm, of my- 
celium and spores. These mycelium and spores differ, 
however, from those of the ringworm, in that the my- 



214 LECTURES IN DERMATOLOGY. 

celium are shorter, are usually empty, and contain very few 
spores and granules, and that the spores collect in groups. 

Etiology. The disease is contagious undoubtedly, but 
to a very limited degree. It never occurs in infants, and 
seldom in children. It is more common in persons who 
perspire freely, and in those suffering from wasting 
diseases, as consumption. 

Symptoms. The disease usually begins on the back or 
chest, or about the shoulders, as slightly elevated, yellow- 
ish spots, about the size of a pin-head, and slightly scaly. 
The spots increase in number and size, and running 
together produce large, irregular patches larger than the 
palm of the hand, but usually surrounded by the smaller 
pin-head lesions, thus giving the skin a mapped appear- 
ance, the patches being the mainland, and the smaller 
ones the islands. The larger patches are usually a little 
elevated, sharply defined, reddish-yellow, or buff color, 
and covered with a furfuraceous desquamation. The 
scaling is made more apparent by scratching the surface, 
but the scales are usually very fine, and not very abun- 
dant. The disease is attended by some itching, but 
frequently not sufficient to attract the patient's attention. 
There are so few symptoms connected with the disease 
that I presume some of you have it, and are not aware of 
your affliction. The disease is almost always limited to 
the trunk, never appearing on the hands, feet, or scalp, 
and very seldom on the face. 

Course. The disease usually spreads slowly, and lasts 
for months or years without treatment, but may undergo 
a spontaneous cure. Relapses, even when treatment is 
faithfully carried out, are common. 

Diagnosis. A differential diagnosis must be made 
between tinea versicolor and chloasma, leucoderma, sebor- 



TINEA VERSICOLOR. 215 

rhcea, erythematous eczema, and erythematous syphilide. 
As in the other varieties of the vegetable parasitic dis- 
ease, the diagnosis is rendered positive by aid of the 
microscope. 

Treatment. As the disease is a very superficial one and 
confined to the horny layers of the epidermis, treatment 
is usually simple and satisfactory. Hot water, sulphur 
soap, and toilet pumice stone are usually all the reme- 
dies you will require. Form a lather with the soap and 
water and scrub the affected area with the pumice stone 
•every other night, which will usually cure the disease. 
Painting the lesion over with tincture of iodine a few 
times will have the same result. Lotions of sulphurous 
acid 10 per cent., or bichloride of mercury \ per cent., are 
satisfactory applications. It has been a matter of obser- 
vation with me that the parasite will not grow under an 
adhesive plaster of any kind, so if you cover the surface 
of the disease with a belladonna or capsicum plaster and 
let it remain for a week or ten days, on removing it you 
will find the trouble has disappeared. 



LECTURE XV. 

TUBERCULOSIS OF THE SKIN, URTICARIA AND 1 
VERRUCA. 

TUBERCULOSIS OF THE SKIN. 

Gentlemen : 

There are four varieties of tuberculosis of the skin : 

I. Miliary, which runs a chronic course and is second- 
ary to phthisis ; 

II. Tuberculosis verrucosa cutis, and verruca necro- 
genica ; 

III. Scrofuloderma; and 

IV. Lupus vulgaris. 

I. The miliary form is rare. Usually appears about 
the corners of the mouth in the form of flat, very painful 
sores of irregular formation, the edges having an eaten-out 
appearance. -The cases are so few in number that it is 
not necessary for me to describe the lesions to you in 
detail. 

II. The second variety, tuberculosis verrucosa cutis, is 
very much more common, and the variety you will most 
generally meet with. The lesions are located on the 
hands and lower flexor of the forearm, most often on the 
backs of the hands or fingers, especially about the knuc- 
kles. They appear in the form of round, elevated plaques, 
varying in size, either single or multiple, on one or both 
hands. In a short time a bright red line develops about 

216 



TUBERCULOSIS OF THE SKIN. 2 1/ 

the plaque, and in it superficial pustules make their 
appearance. An erythematous redness extends from the 
healthy skin about the lesion. In the course of a few 
weeks the plaque becomes covered with warty growths 
or papillomata covered with horny scales. Between the 
papillary growths small pustules form from time to time 
and rupturing dry, forming scabs and crusts. After a time 
the formation of pus ceases, and the crusts consist only 
of epidermic scales. After lasting for some months the 
lesions may dry up and disappear, leaving superficial scars. 
Over the edges of these scars new plaques may make 
their appearance from time to time, giving a serpiginous 
form to many of the lesions. No general tubercular in- 
volvement occurs, but the tubercle bacilli are found 
present in the lesions. 

Etiology. The disease is always the result of inocula- 
tion of the skin with the tubercle bacillus, and is most 
frequently seen in men. The disease is purely local, and 
does not produce tuberculosis elsewhere in the body. 

Diagnosis. There are but two or three diseases which 
you are likely to confound with this variety of tubercu- 
losis. They are lupus vulgaris, tubercular syphilide, and 
possibly sarcoma of the skin. 

Treatment. The growth must be entirely destroyed, or 
it will return. There are two methods of treatment which 
I can recommend ; sometimes you may employ one, some- 
times the other. The growth may be entirely curetted 
away and then treated with pyrogallic acid, as was recom- 
mended in the treatment of lupus vulgaris, or it may be 
completely excised, the edges of the wound brought 
together, and healing made to take place by first intention. 
The only application which seems to be of any advantage 
outside of caustics in destroying the growth, is a 10 to 2Q 



2 1 8 LECTURES IN DERMA TOLOG Y. 

per cent, salicyliated plaster containing I to 2 per cent, of 
beechwood creosote. 

Verruca necrogenica, a form of the second variety, is 
almost always the result of inoculation with tubercular 
material, and sometimes described inaccurately as "dis- 
secting wound." The changes produced are partly cutane- 
ous, partly subcutaneous. The changes consist in the 
formation of a tubercle, purplish in color, which goes on 
to suppuration, breaks down, discharging a small amount 
of pus, and then forms a warty growth. The subcutane- 
ous change consists in the formation of cold abscesses. An 
infiltrated area appears about these tubercles, which in 
turn breaks down, producing pus, and then grows warty in 
character. The process is apt to extend in the periphery 
while healing in the centre. It is purely a local process, 
which may end, in a few weeks or months, in recovery. 

Treatment. The best treatment for this variety of 
tuberculosis of the skin consists of the thorough use of 
the curette, and subsequent treatment with pyrogallic or 
applications of pure beechwood creosote to the diseased 
tissue. 

III. Scrofuloderma. There are two varieties of scro- 
fuloderma, {a) In the first variety, which is the most 
common, it begins in one or more of the superficial lym- 
phatic glands, especially under the jaw, about the neck, 
or clavicular regions. The glands become enlarged, and 
the process extends to the skin overlying them, which 
becomes red and infiltrated. The glands break down, 
forming a cold abscess, which discharges through the 
infiltrated skin, leaving an ulcer of slow progress with 
undermined, violaceous border, which heals very slowly, 
leaving often unsightly scars, which are very prone to 
degenerate and form ulcers. 



TUBERCULOSIS OF THE SKIN. 219 

(b) The second variety is called scrofulous nodes, or 
scrofulous gummata, on account of their resemblance to 
syphilitic gummata. The most superficial of these lesions 
begin as little infiltrations in the skin, of a livid, red color, 
increasing in size slowly at first and later more rapidly. 
It extends in one or more directions, involving the whole 
thickness of the skin, softening at one or more points to 
form small ulcers, which burrow, leaving sinuses, they 
extending from one opening in the skin to another. 
The discharge from these ulcers is usually sero-purulent, 
occasionally bloody, and the skin of the affected region 
becomes undermined by numerous connecting galleries. 
Occasionally the disease takes on a diffuse, infiltrated 
form, spreading in an irregular patch over the skin, giving 
rise to serpiginous, shallow ulcers. The scrofulous ulcers 
never show any disposition to heal. It may look as 
though it were on the very verge of cicatrization, but it 
does not actually heal over, or if it does in a week or two 
the cicatrization breaks down and the ulceration continues. 

Diagnosis. Scrofulous ulcers must be carefully diag- 
nosed from other forms of ulcers, especially the syphilitic 
and the lupus ulcers, which not infrequently involve 
similar areas. 

Treatment. The treatment of scrofuloderma is both 
general and local. Cod-liver oil, iodides, usually in the 
form of iodide of potash, iron, or mercury, seem about the 
best internal forms of medicines. Locally the ulcers may 
be treated with stimulating ointments, preferably those 
containing mercury, the white precipitate ointment being 
a very useful one. Scraping and curetting of the ulcers 
with a sharp spoon and dusting with iodoform is often 
beneficial. Iodoform in glycerine or oil may be injected 
in scrofulous glands. Crocker recommends chaulinoogra 



220 LECTURES IN DERMATOLOGY. 

oil in ten- to thirty-drop doses, with the external use of 
the same oil made in form of an ointment, three drachms 
to the ounce. 

IV. Lupus vulgaris. The fourth variety of lupus of 
the skin we have already studied under the term of lupus 
vulgaris. 

URTICARIA. 

A very common disease of the skin is urticaria or hives. 
Doubtless many of you have at one time or another 
suffered from it. 

Pathology. It is an acute, inflammatory process taking 
place in the papular layers of the skin, seriously affecting 
the circulation and nerve supply of the area attacked. 
In the centre of the lesion the blood supply is most 
diminished, but increases in the periphery, and also per- 
haps in the deeper layers of the corium beneath. The 
affected area of skin is cedematous, and the blood and 
lymphatic vessels near-by found surrounded by leucocytes. 
When the serous exudation becomes extensive the epi- 
dermis is raised up, forming a vesicle or bulla, when the 
disease becomes known as vesicular urticaria. 

Etiology. The cause of urticaria may be either external 
or internal. Among the most common external causes 
are insect bites and irritating substances, as cowhage or 
nettle. Among the most frequent internal causes are 
certain kinds of food, as shell-fish, strawberries, veal, pork, 
etc. Such articles of food, by setting up a gastrointes- 
tinal derangement in some persons, produce through the 
vaso-motor system an urticaria. Certain drugs, especially 
copaiva, cubebs, turpentine, chloral, quinine, and anti- 
pyrene, have frequently the same effect on the skin when 
taken internally. Other forms of intestinal irritation — as 



TUBERCULOSIS OF THE SKIN. 221 

that due to worms — will frequently excite urticarial erup- 
tions. Agents acting directly on the nervous system are 
frequently the cause of urticaria. Sudden emotion or 
shock, especially in females, will be followed by an attack 
of this disease. Spinal irritation and various nerve 
lesions, especially with neuralgic symptoms, predispose 
towards it. Organic diseases of the kidneys or uterus, 
and general diseases of the blood, as purpura and rheu- 
matism, are frequently complicated by urticarial attacks, 
which often become chronic. Urticaria is one of the 
most frequent eruptions in early pregnancy. 

Symptoms. The first local symptoms noticed are burn- 
ing, stinging sensations in the skin, like those produced 
by the sting of nettles. This produces an itching, which 
the patient tries to relieve by scratching, and causes 
efflorescences to appear. The lesions make their appear- 
ance suddenly, and consist mostly of wheals of variable 
size, color, and shape. They are usually not larger than 
a dime and round, but a number may coalesce, producing 
large patches of irregular shape. In color they are whitish 
or pinkish, and surrounded by an areola. The lesions are 
usually elevated, flat, and hard. The skin becomes very 
irritable, so that slight irritation as by scratching will be 
followed by the production of a welt or wheal. The 
number of lesions and the extent of surface affected vary 
much in different cases, but generally the lesions appear 
suddenly in groups, and affect only a portion of the body 
at a time. After remaining on one part of the body 
for a few hours it may appear in a different locality. 
There are no regions of predilection, as the whole surface 
of the body and the mucous membranes are liable to its 
attacks, but it is more apt to occur on those parts most 
likely to become hypersemic from pressure or friction from 



222 LECTURES IN DERMATOLOGY. 

the clothing. It comes at any period of life, but is more 
apt to attack children than aged adults. In children 
there is especially apt to be more constitutional symptoms 
accompanying the attack, as slight fever and gastro- 
intestinal disturbance.* In some cases of urticaria the 
exudation in the skin becomes so great as to form vesicles 
or bullae on the surface of the wheals. 

Course. The disease is usually one of short duration, 
the individual lesions lasting but a few hours, and the 
disease but a few days, during which time frequently 
exacerbations are likely to take place. Occasionally the 
disease becomes chronic, lasting for months or years. 
Here again the individual lesions do not last out much 
longer than a few hours or days, but new ones continue 
to make their appearance, so that the patient is seldom 
free from them. In these chronic forms, especially when 
occurring in children, the lesions may remain for some 
time, and assume a yellowish color, which, upon dis- 
appearing, leaves a brownish stain or pigmentation, which 
is permanent. 

Diagnosis. Urticaria is so common, and its symptoms 
and lesions so pronounced, that the diagnosis is seldom 
difficult. It has, however, been mistaken for erythema 
nodosum, erythema multiforme, erythema simplex, insect 
bites, erysipelas, and eczema. 

Treatment. The cause of the disease should be deter- 
mined, if possible, and removed. It is usually well to be- 
gin treatment with a calomel purge, followed by a dose of 
castor oil, and the patient kept on a bread and milk diet. 
When the disease shows a tendency to return, alkalies 
should be given before meals, and the diet restricted. To 
allay the irritability of the skin alkaline and bran baths 
are very serviceable, and had best be given hot. 



TUBERCULOSIS OF THE SKIN. 223 

Acid, boracic, 
Acid, carbolic, 

Sodii bicarb aa gr. viii 

Glycerini 3 i 

Aq. picis ad 3 i 



m 



is a very good lotion to allay the irritability of the skin. 
Some patients are relieved by sponging the body with hot 
vinegar once or twice a day. When bullae form, the 
treatment should be very mild, and applications of some 
drying or astringent ointment applied. A diachylon 
ointment with a 5 per cent, salicylic acid in it is very 
beneficial. There is no special treatment for urticaria 
pigmentosa. Relapsing or chronic urticaria may be decid- 
edly benefited by giving large doses of jaborandi. 

VERRUCA. 

You will frequently be called upon to treat a very com- 
mon affection, called verrucas or warts. 

Pathology. The pathology of warts differs somewhat 
according to the variety, but they all consist of circum- 
scribed hypertrophies of the papillary layer of the skin. 
The epidermis on the surface also becomes hypertrophied. 
The blood-vessels supplying the papillary hypertrophies 
are increased in size and number, especially in some 
varieties of warts. 

Etiology. There seems to be in many cases an heredi- 
tary tendency to the formation of warts, for we find them 
more frequently in some families than in others. By 
many they are supposed to be directly contagious, and 
may be produced in this way. There is a superstition 
held by many that handling certain animals, especially 



224 LECTURES IN DERMATOLOGY. 

the toad, will produce a crop of warts. Certain irritating 
substances when applied to the skin will set up an inflam- 
matory condition which may result in the formation of 
warts. The irritating secretion from moist warts will 
occasionally, whether from contagion or not I cannot say, 
produce warts of the same variety. Warts most fre- 
quently occur in persons of a strumous diathesis, but may 
occur on persons of healthy constitution. 

Symptoms. Warts most frequently occur in children 
and young adults, and are of five varieties. 

(a) Verruca vulgaris is the most common variety, and 
occurs most frequently on the hands. They are firm, 
circumscribed, round growths about the size of a pea, 
rough or smooth on the surface, but always horny. The 
color is usually darker than the surrounding skin, and 
may be nearly black. They often occur in large numbers, 
and grouped. They are frequently fissured or cracked, 
and then become painful and bleed easily. 

{b) Verruca plana differs from the vulgaris in being 
usually smooth and flat, but slightly elevated above the 
skin. They occur more frequently about the face, espe- 
cially in old people, and are then called verruca senilis, 
and not infrequently develop into epithelioma. 

(c) Verruca jiliformis is the result of the hypertrophy 
of a single papilla in the skin. They are thread-like pro- 
cesses about one sixth of an inch in length. They ap- 
pear about the face, eyelids, or neck, either single or in 
groups. 

(d) Verruca digit at a always appears upon the scalp. 
They are hard, slightly elevated, and marked at their base 
by a number of digitations looking like feet and giving 
them the appearance of insects. 

(e) Verruca acu?ninatis, or venereal zvarts, or moist 






VERRUCM. 225 

zvarts, almost always make their appearance on the 
genital organs. In the male they occur on the inner 
surface of the glans or prepuce, and in the female on the 
surface of the labia. They are very apt to accompany 
venereal affections as a result of irritating secretion, but 
by no means necessarily so. By many they are considered 
erroneously as contagious. They may appear upon any 
moist surface, as about the anus or between the toes, 
where there are heat and moisture. These warts are of 
various size, from a thread to a hen's egg, or even larger. 
The smaller ones are usually pedunculated. Some appear 
as masses of vegetation, called cauliflower warts, others as 
flat, fleshy excrescences. They grow very rapidly, usually 
multiple, and may become confluent, producing large 
masses of cauliflower growths. They are usually vesicu- 
lar, pink or red in color, and when moist secrete a semi- 
purulent fluid, which decomposes readily, producing an 
offensive odor. This secretion may dry upon the surface, 
producing crusts. 

Diagnosis. The diagnosis of warts is usually very easy. 
Occasionally they are mistaken for epitheliomata or tuber- 
cular affections of the skin, but in the large majority of 
cases you will have no difficulty in distinguishing these 
diseases from simple warts. 

Treatment. The best and quickest treatment for hard 
warts when there are but two or three present is to snip 
them off with a pair of scissors, and touch the bases with 
a stick of nitrate of silver. If your patient objects to 
this surgical procedure, the best caustic to apply is nitric 
acid every second or third day. A slower but less painful 
way, and one especially to be recommended where the 
warts are numerous, is the application every second or 
third day of a 10 per cent, solution of salicylic acid in 



226 LECTURES IN DERMATOLOGY. 

flexible collodion. Before each application the warts 
should be scrubbed and cleansed with soap and hot water, 
then thoroughly dried. 

The soft or venereal warts should be treated with 
applications of glacial acetic acid every day or two, and 
dusted over with calomel twice a day, after thoroughly 
cleansing with hot water and castile soap. If there are 
much heat and moisture the parts should be kept sepa- 
rated with lint or wool. Some of the large, flat excrescen- 
ces will not yield to this treatment, when chromic acid, or 
the galvano-cautery must be applied to remove them. The 
only internal remedy in which any confidence can be 
placed, is the thuya occidentalis. This remedy may also 
be applied externally at the same time. 

This, Gentlemen, finishes my course of lectures in derma- 
tology, which I have mapped out for you. In the few 
moments which I have left I cannot employ the time 
more profitably than to read to you some dermatological 
" Don'ts," to which I am indebted to my friend, Dr. G. T. 
Jackson, of New York. 

SOME DERMATOLOGICAL DON'TS. 

Don't make your diagnosis from the history of a case, 
because if you do you will often be led astray. Make it 
from the eruption that you see, and then substantiate or 
destroy this by the history of the case, if you will. 

Don't fail to think of the possibility of every case being 
either syphilis or eczema ; and 

Don't fail to master these two diseases as thoroughly as 
possible ; because, if you learn to recognize these two, you 
will have gone a long way in diagnosis. If they can be 
excluded, then the field of possible " might be's " is con- 
siderably narrowed. 



DERMA TOLQGICAL DON' TS. 227 

Don't make the diagnosis of syphilis on account of a 
syphilitic history, because you can often get a history of 
syphilis in a non-syphilitic case. 

Don't expect much, if any, history of syphilis in a 
woman, because you very frequently will not get it. This 
is not because they are " gay deceivers," but because in 
them the early symptoms of the disease are often so 
slight that they are not observed by them. 

Don't throw out the diagnosis of syphilis on account of 
an eruption itching, because some syphilides, especially in 
the papular variety, do itch at times. The not itching 
of an eruption is better presumptive evidence of syphilis 
than is itching positive evidence against it. 

Don't make the diagnosis of lichen planus from the 
presence of flat angular papules with depressed centres 
alone, because identical lesions will at times be met with 
in eczema, syphilis, and psoriasis. 

Don't depend upon getting the bleeding-points 
springing out of the delicate pellicle after carefully 
scraping off the scales for your diagnosis of psoriasis, 
because you can produce the same thing in other diseases. 
In fact, 

Don't depend upon any one symptom, but make your 
diagnosis from the general make-up of the disease as a 
whole. 

Don't forget that many diseases of the skin are de- 
pendent upon disturbances in the general health of the 
patient. Therefore, 

Don't fail to inquire into the performance of the func- 
tions of the various organs of the patient, and to put him 
into as good a physical condition as possible. 

Don't tell your patient that it is dangerous to cure his 
skin disease rapidly, because it is not. If you 



228 LECTURES IN DERMATOLOGY. 

Don't know how to treat the case, ask advice of some 
one who does. 

Don't encourage the popular notion that there is danger 
of an eruption striking in, because it never does. 

Don't give arsenic for every skin disease ; and, especially, 
Don't give it in acute eruptions. Its sphere is in the 
chronic scaly eruptions, such as chronic psoriasis. 

Don't forget that most cases of pruritus are due to in- 
ternal causes, and that in them external treatment is 
wasted ; and 

Don't forget the bed-bug and the pcdiculus as possible 
causes of the trouble. 

Don't forget that the greatest secret in the treatment of 
eczema, and many other skin diseases, is not what particu- 
lar drug or formula is "good for" the disease, but a 
knowledge of the great principle that acute diseases need 
soothing remedies, and subacute and chronic diseases 
need stimulation. 

Don't expect to cure an inveterate eczema with thick- 
ened skin by means of a soothing ointment, such as that 
of the oxide of zinc, because you will only waste your 
time and the patient's money. 

Don't use tar in an acute eczema, because it is a stimu- 
lant, and what we want at this time is to soothe the in- 
flamed skin. It is appropriate to a subacute or chronic 
case. 

Don't allow water to touch any form of eczema, because 
it always irritates in such a case. 

Don't use a thick ointment on the hairy scalp, because 
it makes a disagreeable mess of the hair and will not be 
" popular " with your patient. Even lard is not a pleasant 
vehicle for such applications. Vaseline and the oils are 
more elegant excipients. 



DERMA TOLOGICAL DON* TS. l2<) 

Don't order the hair to be cut from the head of a young 
or old woman in any disease of the scalp, because, except 
in the case of a peculiarly stupid or careless patient, it is 
never necessary, and always disagreeable to the woman. 

Don't allow a patient with ringworm to go to school, 
because if you do you will be responsible for the spread 
of the disease. 

Don't pronounce a ringworm case well and incapable 
of spreading the disease until you are sure that it is well ; 
and 

Don't be sure about it until there are no more 
"stumps " on the scalp, and you can find no more of the 
fungus in the hair. 

Don't use the name " barber's itch " for anything but 
trichophytosis barbae, because it is well not to use terms 
loosely to cover several different diseases. 

Don't use chrysarobin on the face or scalp, because it 
is very apt to cause a good deal of dermatitis with 
oedema, and to stain the skin a deep mahogany-red. 

Don't forget to caution a patient to whom you have 
given chrysarobin not to touch his face with his hands 
after applying the drug, because if you do you will have 
either a mad or frightened patient in your office. 

Don't pronounce a patient addicted to the excessive 
use of alcoholic beverages on account of his having 
rosacea, because there are lots of other things besides 
alcohol that will cause it. 

Don't use the positive pole of the battery for the needle 
in destroying hair by electrolysis, because if you do you 
will leave more or less permanent marks in the skin. 

Don't apply a sulphur preparation after using a mercu- 
rial upon the face, or vice versa, because if you do you 
will raise a fine crop of comedones. 



230 LECTURES I.\ T DERMATOLOGY. 

Don't use a camel's-hair brush for making applications 
of corrosive sublimate, because if you do some of the salt 
will be left on the brush each time it is used, and you 
soon will have a stronger solution than you bargained for. 
Always use a little cotton on a wooden toothpick, or a 
splinter of wood. 

Don't allow a fine-toothed comb to be used on the scalp, 
because it scratches and irritates the scalp. 

Don't encourage or advise the use of pomades on the 
healthy scalp, because they are prone to become rancid 
and inflame the scalp. They are also unnecessary if the 
hygiene of the scalp is properly looked after. 

Don't forget that dandruff is the most frequent cause of 
premature baldness, because if you remember this you may 
be able to prevent the fall of some one's hair for some time. 
Therefore, 

Don't forget to treat every case of dandruff. 

Dr. Jackson neglected to add one more don't which is 
very important — 

Don't forget to study Dr. Cutler's " Differential Diag- 
nosis of the Diseases of the Skin," published by G. P. 
Putnams Sons of New York. 



INDEX. 



PAGE. 
3 1 

52 
19 

39 



Achorion Schoenleinii 

Acne 

Addison's disease 

Alkaline diuretics 

Alopecia . 

" areata 

" furfuracea 

Anatomy of the skin 

Arsenic in skin diseases 

Asteatosis 



Barber's itch ...... 209 

Bassorin 22 

Baths 27 

Birth-mark 145 

Black-heads ...... 57 

Blind boils 104 

Body lice 148 

Koils 101 

Bromidrosis 100 

Bullous skin diseases g 

" syphilide ..... 199 

C 

Capillary nsevus ..... 145 

Caustics 28 

Chloasma 50 

Chronic eczema 71 

Classification of skin diseases . . 6 

Clavus . 53 

Cod-liver oil 18 



Collodion ...... 25 

Comedo ....... 57 

Condylomata ...... 188 

Corns ....... 53 

Crab-lice 149 



Dandruff. 
Dermatitis 

" venenata 

Dermatological don'ts . 
Diagnosis of skin diseases 
Diseases of the skin 
Dry tetter 



Ecthyma 






. 62 


" syphilitica 






. 192 


Eczema . . 






• 65 


" erythematous 






. 69 


" marginatum 






. 205 


" papular 






• 71 


" pustular 






. 70 


" rubrum 






• 7 2 


' seborrhoeicum 






• 178 


' squamous . 






■ 73 


1 vesicular 






. 69 


Epithelioma . 






. 80 


Ergot in skin diseases 






• 19 


Erythematous eczema 






. 69 


" syphilide 




. 186 


External medication 






. 20 



231 



232 



INDEX. 



Favus 200 

Feigned skin diseases . . -99 

Freckles 124 

Furunculosis ...... 101 



Gelatine 

plasters 
Glyco-gelatines 
Gnmmala 

Gummatous syphilide 
Gummy tumor 



H 



Head lice 

Hereditary syphilis 
Herpes . . . 

" circinatus 

" facialis 

progenitalis 

" simplex 

" zoster . 
Hirsuties 
Hives 

Hyperidrosis . 
Hypertrichosis 
Hypodermatic medication 



Lesions of the skin 

Leucoderma 

Lichen 

" planus . 

" syphiliticus . 

" trophicus 
Lotions 

Lupus erythematosus 
' vulgaris 



M 

Macular skin diseases 

syphilide . 
Mercury in skin diseases 
Microsporom furfur 
Miliaria papulosa . 

" vesiculosa 
Milium . 

Moles . 

Molluscum contagiosum 
Mother's mark 
Mucous patch . 

N 



Ichthyosis .... 
Impetigo ..... 

" contagiosa 

" syphilitica 
Instruments used in dermatology 
Internal medication in skin disease: 
Iodide of potash . 



Keloid . 
Keratosis pilaris 



Lassar': 



Ointment n 
Ointments 



1 ] in I 1 



eczema 70 

" skin diseases .... 9 

" syphilide . . . . 187 

Papulo-squamous syphilide . 1S9 

Parasitic sycosis 209 

Pediculosis 146 

" capitis 147 

" corporis . .140 

" pubis . . . '49 

Pemphigus 149 

Pigmentary syphilide .... 190 

Pityriasis rosea 152 

" versicolor .... 213 



Lentigo ,24 Plasment . 



Powders . 
Prickly heat . 
Pruritus . 
Psoriasis . 
Purpura . 

" hemorrhagica 

rheumatica 
" simplex 
Pustular eczema 

skin diseases 
" syphilide . 



Ringworm 

" of the beard 

" " body 
" " scalp 

Rodent ulcer . 

Rosacea . 

Rupia 





INDEX. 


233 


PAGE. 




PAGE. 


. 26 


Syphilide, gummatous . 


• »93 




130 


pustular 


. 190 




'53 


Syphilitic psoriasis 


. . .89 




'57 


Syphilis .... 


. 185 




'9 


Syphilodermata 


. • 185 



71 


Teleangiectasis 








'4i 


9 


Therapeutics of skin diseases 




15 


190 


Tinea 






200 




barbae . 








209 




circinata 








203 




" favosa . 








200 


?02 


tonsurans 








207 




trichophytina 








202 


20.' 


versicolor 








213 


207 


'I raumaticin . 








2S 


8l 


Tubercular skin diseases 






9 


169 


" syphilide 






192 




Tuberculosis verrucosa cutis 




216 




Tumorous skin diseases 








9 



Scabies 

Scrofuloderma 
Scrofulous gummata 

" nodes . 

Seborrhcea 

" capitis . 

" oleosa 

Seborrhoeal eczema 

Shingles . 

Soaps 

Strawberry mark 

Sudamina 

Sweating 

Sycosis parasitica . 

" vulgaris 
Syphilide, erythematous 
" macular 

papular . 
papulo-squ; 
Syphilide, pigmentary 
" tubercular 



V 



Venereal warts 223 

Verruca 223 

" acuminatis 224 

' digitata ..... 224 
1 filiformis ..... 224 
" plana ...... 224 

vulgaris 224 

Vesicular skin diseases .... 9 
Vitiligo ....... 127 

W 
Warts 223 

X 
Xeroderma 49 



